Experiences of undergraduate nursing students who worked clinically during the COVID-19 pandemic.

AIM: This study explored the experiences of undergraduate nursing students who worked clinically during the COVID-19 pandemic in Irish healthcare settings.
DESIGN: A qualitative descriptive approach was employed.
METHODS: Online focus group interviews were used to collect data from general nursing students (N = 47) between February and April 2021. Data were analysed using thematic analysis.
RESULTS: Descriptive thematic analysis of the data revealed five themes; changes in care delivery, changes in communication and relationships with the patient, an emotionally charged work atmosphere, coping strategies during the pandemic and student learning specific to COVID-19. Challenges such as an increased workload, fear of contracting the virus and taking on novel and additional roles were revealed. Students remained undeterred, and despite the many challenges faced, they largely viewed their experiences as a source of personal and professional growth, and benefitted from the learning opportunities afforded to them.

INTRODUCTION AND BACKGROUND

In March 2021, the World Health Organization declared COVID‐19 a global pandemic (Adhanom, 2020). As COVID‐19 spread around the world, healthcare services had to restructure to meet clinical needs. As the number of COVID‐19 hospital admissions increased, so too did the requirement for more healthcare personnel, especially nursing staff (Department of Health, 2021). Many non‐essential services were either cut back or suspended, and staff redeployed to cope with an ever‐increasing clinical demand.

Lovrić et al. (2020) contend that a crisis such as COVID‐19 has the potential to negatively impact the psychological well‐being and functioning of nursing students. Despite this, the impact of clinical placement experience on nursing students during a pandemic remains unclear (Goni‐Fuste et al., 2021). There is some evidence to suggest nursing students may be at risk psychologically during crises such as the COVID‐19 pandemic (Savitsky et al., 2021). A cross‐sectional study by Ulenaers et al. (2021) explored nursing students' experiences during the COVID‐19 pandemic in nine Belgian nursing schools. Respondents reported a need for more psychosocial support, regular contact with clinical placement supervisors and identified that the pandemic had a noticeable impact on students' clinical experience. Moreover, Swift et al. (2020) recognized that nursing students frequently experienced an emotional conflict between their need to protect themselves and their loved ones with their desire to care for those who were ill during the COVID‐19 pandemic.

In Ireland, all nursing students' clinical placements were suspended (Department of Health, 2021) and clinical nursing support staff were redeployed as staff nurses. To further meet clinical demands, nursing students were offered temporary remunerated employment as healthcare assistants (HCA). The HCA grade was introduced to the health service in 2001. HCA's are a separate occupational grouping of health service employees who support the functioning of nursing teams. Being offered employment as a HCA resulted in students being able to decide whether or not they wished to work in the clinical setting during the pandemic. Many nursing students accepted this employment and thus had direct patient contact during the pandemic crisis.

This qualitative study aims to explore the experience of Irish undergraduate nursing students who worked clinically during the COVID‐19 pandemic. This research was carried out a year into the pandemic (January 2021–June 2021) when nursing students were not in the midst of this crisis, but rather in a position to reflect on the experience with the benefit of hindsight.

METHODS

Design

This study employed a qualitative descriptive approach based on the work of Sandelowski (2000). While qualitative description is reported to be the least theoretical of the qualitative research designs, it allowed the exploration of study participants' real‐life experiences without having to adopt already existing philosophies or theories (Sandelowski, 2000).

This research is presented according to the Standards for Reporting Qualitative Research (SRQR) checklist, facilitating research transparency and assisting the maintenance of an audit trail of the qualitative research process (O'Brien et al., 2014).

Participants and recruitment

As part of the clinical instruction for the undergraduate nurse registration programme, and in compliance with legislation pertaining to the nursing standards (Nursing & Midwifery Board of Ireland [NMBI], 2016), an allocation officer in the University has the responsibility for organizing and planning students' clinical placement. In total, students must complete at least 2300 clinical hours over a 4‐year period (NMBI, 2016). Clinical instruction is divided into generalist and specialist medicine, generalist and specialist surgery, care of the older person, primary health and community nursing, specialist placement and regulated internship placement. Students attend clinical placement for 35 hours per week, inclusive of 4 hours for protective learning in years one, two and three of their programme. From January to November of year four, internship students complete 39 hours per week over a 36‐week period. As part of the student's progression, they must demonstrate competence as part of their assessment reflective of the Steinaker and Bell (1979) experiential taxonomy. While working as a HCA, students were permitted to allocate 6 weeks of time spent in this role towards their clinical placement hours.

Purposeful sampling was used to recruit nursing students from a nursing department in an Irish University. Students across all 4 years of a BSc. (Hons) in General Nursing programme received an invitation to participate in the study via their student email (N = 159). Students who met the following inclusion criteria were included in the study: (1) currently enrolled on the BSc. (Hons) in General Nursing programme and (2) aged 18 years and over. A total of 60 respondents initially accepted the invitation to participate in the study, subsequently a sample size of 47 attended for focus group semi‐structured interviews. Of the 47 students sampled, 14 were in year one of the programme, 10 students were in year two, 14 were in year three, and nine students were in year four. Only one male student selected to participate while the remaining 46 students were female. Most students were aged between 18 and 28 years, six students were aged between 29 and 38 years, and two students were aged between 39 and 48 years.

Data collection

Qualitative interviews provide opportunities to explore the unique experiences of the interviewees in an in‐depth manner (McGrath et al., 2019). Focus group interviews are particularly useful when little is known about the topic, allowing for discussion amongst participants to increase the depth of the inquiry (Doody et al., 2013; Gray & Grove, 2021; Padgett, 2017). Nursing students' experiences were explored using an interview guide created by the research team. Researchers consulted scholarly literature, to identify possible concepts to explore and to determine the type of questions posed by other interviewers in studies of a similar topic. Following an interview guide ensured that all participants were asked the same questions, guaranteeing consistency and reliability.

Students were asked at the start of each interview to describe their experience of being on placement during the COVID‐19 pandemic. This broad and open‐ended question allowed scope and flexibility for the participant to tell their personal story. Other examples of questions asked were to describe the difficulties or challenges students encountered on placement during the pandemic, the strategies used to overcome these challenges, what supports students had available to them on placement, what learning had taken place on placement specific to COVID‐19 and whether their level of training prepared them for the work carried out as a nursing student during the pandemic.

Thirteen focus groups interviews, with groupings of three to six participants, were conducted online between January 2020 and April 2020 via the Zoom online videoconferencing tool incorporating both audio and visual recordings. An interviewer and a moderator were present for all online interviews, which lasted approximately 40 minutes. Moderators mostly assumed the role of an active listener during interviews, ensuring that the interviewer did not deviate from the interview guide. Notably, they also summarized what was said by participants on completion of the interview, confirming that they understood the reported responses of participants (McGrath et al., 2019). This process of debriefing the analytical results with participants facilitated agreement and accuracy of the interpretation of participant replies. This not only augmented credibility of the spoken word but also strengthened the validity and reliability of data (Creswell & Creswell, 2017; Toles & Barroso, 2018). All interviews were transcribed verbatim. While inter‐person interactions are customarily the “gold standard” in qualitative research (Reñosa et al., 2021), utilizing the online platform of Zoom abridged the restrictions of being unable to conduct face‐to‐face interviews, with limited impact on data (Creswell & Poth, 2018; Seidman, 2019). The use of Zoom for virtual focus group interviews is also identified to aid uninterrupted research with low dropout rates during the COVID‐19 pandemic (Halliday et al., 2021).

Data analysis

Data were analysed using thematic analysis as outlined by Braun and Clarke (2006). Descriptive thematic analysis of the data revealed five themes which will be discussed in this paper: changes in care delivery, changes in communication and relationships with the patient, an emotionally charged work atmosphere, coping strategies during the pandemic and student learning specific to COVID‐19. All researchers were involved in identifying themes which repeatedly occurred using the recordings and transcripts for verification. Researchers shared all access to original data for the purpose of transparency, trustworthiness and verification of the spoken word of the participant. NVivo (QSR International Pty Ltd. Version 10, 2014) qualitative data analysis software managed the data and assisted to record data movements, patterns of coding and mapping of conceptual groupings, facilitating transparency of data analysis.

A coding framework (Table 1) was developed where four members of the research team independently analysed, processed and coded a single transcript in NVivo and then came together to compare and affirm the transformed raw data into agreed themes. The meaningful concepts presented in the data were then grouped into the coding framework, with subsequent codes identified during the content analysis stage. Following this, the entire research team met, reprocessed and transformed derived themes by allowing each team member to repeat the analysis independently and recontextualise to ensure the trustworthiness of the data (Lincoln & Guba, 1985).

TABLE 1

Coding framework

Initial codes (descriptive)	Refined codes (interpretive)	Final themes (abstract)
Extra responsibilities: positive and negative aspects	Role expansion	Changes in care delivery
Staff shortages
Providing cluster care to patients: Limited time with the patient
Taking on the role of the family	Family role	Changes in communication and relationships with the patient
Students perceived role importance
Impact of having no visitors on the patient
Facilitating window visits	Facilitating communication
Assisting communication between patient and family via zoom/phone
The impact of PPE on communication	Barriers to effective communication
Fear	Emotional factors	An emotionally charged workplace atmosphere
Worry
Guilt
Stress
Isolation from others
Ambivalent feelings: wanting to help but fear of contracting the virus
Sudden and continuous changes such as ward closures, staff redeployment, increased staff out sick	Environmental factors
Uncertainty, unpredictability, uncontrollability
Changing protocols as the landscape evolved
Financial Issues	Inequity and unfairness
Not put forward for COVID tests or vaccinations
Feeling undervalued/taken for granted/extra pair of hands
Having to give up part‐time job while working clinically to protect hospitalized patients	Moral juxtapositions
Working outside of scope of practice
Reluctance to take on extra roles/refusing to take on additional roles
Feeling valued as part of the team	Teamworking
Confidence boost
“we are in this together”
Getting out of the house to work clinically	Keeping busy	Coping strategies during the pandemic
Distraction: walking, listening to music, Netflix
Support of family, developing bonds, reconnecting	Spending time with family
Support of other clinical staff	Clinical staff support
Support of peers, WhatsApp groups, debriefing, “they just get it”	Peer support
Supports students would like to have had
Hand hygiene	Infection control	Learning specific to COVID‐19
Donning and doffing
Wearing PPE
Identifying patient deterioration	Identifying patient deterioration
Mental health issues
Sink or swim	Dealing with stress
Weathering the storm
Exposure to death and dying
The importance of communication	The importance of communication
Care of the older person

Lincoln and Guba (1985) identify four principles for evaluating interpretive research which include credibility, confirmability, dependability and transferability. According to Polit and Beck (2014), credibility of the study or confidence in the findings of the study is the overarching consideration. Practices used to confirm credibility in this study were frequent peer debriefings after each interview, meticulous record keeping and writing of reflective notes, the use of a moderator during interviews, the self‐selection of students to voluntarily participate in the research and the analysis of participants verbatim responses.

Confirmability is the degree findings that are consistent and could be repeated. Methods used to enhance confirmability included the maintenance of a detailed audit trail of analysis and recording reflective memos in NVivo. Memos were reviewed and discussed in peer‐debriefing sessions between the research team to achieve consensus and agreement of all decisions made.

Dependability refers to the stability of the data over time and over the conditions of the study (Polit & Beck, 2014). Dependability also includes the procedures employed to minimize researcher bias and to what extent the findings of the study are in accordance with the responses of the participants and not influenced by the researcher's interests. Procedures employed for dependability included the documentation of researcher field notes used to clarify the perspective of the interviewer at the time of data collection thus enabling bracketing to occur. This approach assisted in verifying the authenticity of the research, providing an audit trail from where themes were eventually derived alongside narrative texts in the NVivo software utilized.

The main goal of qualitative research is not to generalize findings, but to provide findings and a detailed description of the research process to enable other researchers to make informed decision about the generalization of the findings in other fields and conditions, should the study be contextually replicated (Gray & Grove, 2021). In this study, the experiences of nursing students who worked clinically during the pandemic were carefully examined. Findings of the study were compared with those of other research studies conducted in the same time period, revealing similar findings to those of our participants' results, which confirmed transferability.

Ethics considerations

Research Ethics Committee approval was obtained from the Research Ethics Committee of the University where the research was conducted. Detailed information pertaining to the study was provided to all undergraduate general nursing students via their student email along with an invitation to participate. Students self‐selected to participate in the research by completing an online consent form. Consent is ongoing in research therefore consent was reconfirmed via the chat box function in Zoom prior to commencement of the interviews. Students were assured that participation was voluntary and incorporated the right to withdraw from the study at any stage. Anonymity of participants outside of the focus group was guaranteed with the use of pseudonyms. No incentives were offered for participation, and students were assured this was an independent research project and not a curricular evaluation of their nursing programme.

RESULTS

Following data analysis, five overarching themes were found to consistently represent the experiences of nursing students who worked clinically during the pandemic, including changes in care delivery, changes in communication and relationships with the patient, an emotionally charged work atmosphere, coping strategies during the pandemic and student learning specific to COVID‐19 (Table 2).

TABLE 2

Overview of themes, sub‐themes, categories and illustrative quotations which describe the experience of nursing students who worked clinically during the COVID‐19 pandemic

Main theme	Sub‐themes	Categories	Quotations
Changes in care delivery	Role expansion	Extra responsibilities for the student Staff shortages	“We were expected to undertake the role of a staff nurse and carry out all tasks that they were expected to do…That was just due to the lack of staff because of COVID‐19” (Ivy, Year 4)
		Moral juxtaposition	“You'd be kind of worried in case something did happen…you would be afraid” (Elizabeth, Year 4)
	Providing cluster care	Cluster care	“You weren't in the patient's room talking to them, getting to know them and getting that person‐centred care. You were just in and out, do your job, and that was it…” (Vicky, Year 3)
Changes in communication and relationships with the patient	Taking on a family role	Substituting for family Visiting restrictions and its impact on the patient	“When they can't have their family coming to visit them and you're the person that they rely on, you start to realise your role and your role's importance even more…” (Michelle, Year 3)
	Maintaining connectedness between patients and families	Facilitating communication for the patient	“…some of the older patients don't have a mobile phone so you've to take the phone to them and set up Zoom calls for them” (Willow, Year 4)
	Barriers to effective communication	Impact of PPE on communication	“My heart went out to patients…Just seeing the emotion and there's nothing you can do because…you have this barrier, you're all gowned up, all they can see are your eyes and it's a communication barrier” (Alice, Year 1)
Emotionally charged work atmosphere	Being part of the team	Feeling valued and part of the team Confidence boost We are all in this together	“One of the biggest things I noticed is teamwork, how important it is to work as a team… the work they do especially in the middle of a pandemic and they just all stick together it makes such a difference” (Sally, Year 1)
	Becoming emotional invested in patient care	End‐of‐life care Family role at end of life	“I found it very difficult knowing that we as student nurses could go into people's rooms that were dying and actually hold their hands and sit with them but then their families couldn't” (Fiona, Year 2)
	The stress responses generate as a result of COVID‐19	Stressors and emotions	“…the fear … you don't know what you're going to be carrying in and you don't want to be infecting anybody and you don't want to be that person who's the one to blame” (Fiona, Year 2)
		Financial issues Inequity and unfairness	“…sometimes the pay you're just looking at it and this is definitely not worth coming into work and just risking, catching it at work and coming back home and then potentially infecting everybody there in your house” (Willow, Year 4)
Coping strategies	Keeping busy as a means of coping	Self‐care mechanisms	“I just kept myself busy…go for a walk if I needed to, watched too many Netflix series! But it kept me busy and occupied” (Beatrice, Year 3)
	The importance of family support	Time spend bonding with family	“Spending more time with the family was a nice side of things…that's one thing COVID did teach us as well, time is very limited, you're here today, you're gone tomorrow, and you just don't know what's around the corner. So, I value the time I have with my family now…we've got a lot closer” (Marilyn, Year 3)
	The importance of peer support	Peer support: sharing the same journey	“The other student nurses going through the same thing helped a lot…I thought that was very reassuring to know that you're not the only one experiencing that, everyone else is having the same feelings” (Fiona, Year 2)
	The importance of clinical staff support	Clinical support	“she was the best preceptor I've ever worked with…she was so good to me, we did a debrief after almost everything, because she knew…we were both working in an environment we'd never been in before” (Nora, Year 3)
Learning specific to COVID	Infection control	Correct use of PPE Hand hygiene	“I learned how important your PPE is and wearing a mask, it really does protect you, and doing your hand hygiene” (Lisette, Year 1)
	“Sink or swim”	Survival	“We learned how to deal with high stress situations, we learned a lot of endurance…I think we did learn a lot, to be able to cope with a lot more than we would usually on a normal placement” (Evie, Year 2)
	“Weathering the storm”	Just get on with it	“…if you can weather this storm, you can weather anything…it was an invaluable, whilst scary experience, it was a great learning curve” (Michelle, Year 3)
	Importance of communication	Communication	“I definitely did learn a lot more talking on this placement than I did in my previous placement…they're not really talking to their families anymore…I feel that I've learned how to communicate with people more than I probably would have” (Siobhan, Year 1)
	Identifying patient deterioration	Trusting your instincts and clinical judgement	“I feel like going with that gut feeling, just reading the patient…you get to know the person and it made me more attuned to going through their readings…being able to say to your nurse with confidence and being able to read people, I feel like I've gotten better at that…I think that's improved” (Geraldine, Year 2)

Changes in care delivery

Major disruptions to the delivery of health care occurred during the COVID‐19 pandemic. Healthcare staff were tasked with meeting the demands of increasing COVID‐19‐positive hospitalizations, coupled with caring for non‐COVID‐19 patients, while trying to minimize the spread of this new contagion. This theme identified how the role of the nursing student changed to adapt to the demands of healthcare provision and how care delivery was also impacted.

Role expansion

In many clinical settings, the workload of staff increased exponentially at this time. Staff shortages impacted the work atmosphere, creating unprecedented pressure on remaining staff to deliver high‐quality care while also supervising and supporting nursing students:

When you were on the wards, you could feel the sense of tiredness from all of the qualified staff. And you could see they were 100% doing their best to try and give us the time to educate us and spend time with us, but they were just tired. (Bella, Year 2)

Role expansion was reported by fourth‐year students who experienced additional responsibilities entrusted onto them due to staff shortages. Participants described taking on extended roles in an effort to alleviate the pressure experienced by staff at that time and to assist where they could provide care to those in need:

with COVID and staff members having to isolate…there were a lot of staff missing from work so the staff numbers were down, so we were expected to undertake the role of a staff nurse and carry out all tasks that they were expected to do…That was just due to the lack of staff because of COVID‐19. (Ivy, Year 4)

Many participants welcomed the additional responsibility; however, a small number described feeling anxious expressing fears of missing something important, making mistakes and feeling insecure about their competence:

You'd be kind of worried in case something did happen…you would be afraid. (Elizabeth, Year 4)

Providing cluster care

Changes in care practices also occurred in the form of cluster care, whereby staff and students had to attend to patient's personal care in a restricted time period. This limitation on time spent with the patient raised concerns by participants that care was often rushed:

You weren't in the patient's room talking to them, getting to know them and getting that person‐centred care. You were just in and out, do your job, and that was it, which was very hard. (Vicky, Year 3)

Changes in communication and relationships with the patient

This theme reflects the role nursing students played in supporting patients during the pandemic. The support needs of patients changed in the absence of their families. Physical barriers such as visiting restrictions, as well as the implementation of PPE wearing by healthcare staff resulted in changes to the way patients, were communicated with and to the relationships students usually had with patients.

Taking on a family role

This subtheme reflects participants' perception of themselves as surrogate family members at a time when patients were without family support. Nursing students felt an onus to fill the void caused by visiting restrictions and made a greater effort to spend more time interacting with patients than they would have made pre‐pandemic:

When they can't have their family coming to visit them and you're the person that they rely on, you start to realise your role and your role's importance even more. And with that, it did add more on to us as student nurses, because they relied more on us. (Michelle, Year 3)

Maintaining connectedness between patients and families

In the absence of in‐person family visits, nursing students facilitated communication between patients and families through alternative means. Examples of these include assisting with pre‐arranged window visits where patients could be positioned at a window to see their family outside and also through the use of digital technology where online video calls were arranged:

You're taking on the family role then as well…telling them who's called and you've called this person to let them know how they're doing because some of the older patients don't have a mobile phone so you've to take the phone to them and set up Zoom calls for them. (Willow, Year 4)

Barriers to effective communication

While identifying the requirement for PPE, it was acknowledged that PPE created an additional communication barrier for patients at a time when they were already disconnected from their world and surroundings:

My heart went out to patients…Just seeing the emotion and there's nothing you can do because…you have this barrier, you're all gowned up, all they can see are your eyes and it's a communication barrier. (Alice, Year 1)

This was especially difficult for patients who had a hearing impairment or for patients with dementia. Facial expressions of staff were hidden while wearing a mask:

The smile is gone. (Faith, Year 2)

An emotionally charged work atmosphere

A range of emotions and feelings experienced by nursing students while working during the pandemic were identified. As previously acknowledged, the clinical landscape was undergoing a dramatic change to cope with increasing demands and the number of patients being hospitalized with COVID‐19. Nursing care processes changed too which had both positive and negative impacts on nursing students.

Being part of the team

An environment buoyed by teamwork was identified by many students. The uncertainty brought on by the pandemic fostered a sense of collegiality where all staff united to work together as a team. There was a palpable sense of “we are all in this together” from participants:

One of the biggest things I noticed is teamwork, how important it is to work as a team. You can feel the supports in the hospital and even the way they've included me is amazing…one said your part of the team, you're one of us. I nearly burst out crying, it just meant the world to me…If you don't have your team you don't have anything and I had so much admiration, even more so now, for the work they do especially in the middle of a pandemic and they just all stick together it makes such a difference. (Sally, Year 1)

While students relished their perceived elevated status in the multidisciplinary team, a cognitive dissonance existed with some students reporting self‐doubt in their ability to take on additional nursing roles while feeling a sense of duty to help clinical colleagues and recognizing the need for patient care to be fulfilled:

There was one day in particular and I was with one staff nurse and she had myself and a pre‐internship nurse…to make up for the nurse that was missing that day, so we were doing some things that we weren't completely trained to do but that one nurse, bless her, she had an awful day, but she was making sure that we had constant supervision in anything we were doing…but we were doing things that you shouldn't really be doing it at this stage. But we had no choice because there is no one else here and this nurse can't do it all on her own. (Helen, Year 2)

Becoming emotionally invested in patient care

Students reported experiences they may not have had in the absence of COVID‐19. One such experience was being present with patients at the end of life when family could not be there. Students recalled these very intimate and difficult moments:

I found it very difficult knowing that we as student nurses could go into people's rooms that were dying and actually hold their hands and sit with them but then their families could not. (Fiona, Year 2)

Taking on the family role took an emotional toll on some participants, resulting in students over‐identifying with patients and finding it hard to switch off:

The mental aspect of it…you're going home thinking of your patients, what could I have done for them today or could I have chatted to them better or they've nobody else coming into them so you're taking on the family role then as well… your patients were becoming more like family members rather than patients. So, you're thinking about them all the time and it just leaves a bit of an impact on your mental health. (Willow, Year 4)

The stress responses generated as a result of COVID‐19

Students referred to many stressors that weighed heavily upon them particularly the changes and uncertainty which generated many emotions for them such as fear, guilt and frustration. An atmosphere of fear pervaded where students picked up on a sense of panic from other staff and patients:

When you see the qualified staff panicking, you're like, oh God. What's going to happen to us? (Abigail, Year 2)

Many participants also expressed fear of contracting COVID‐19 and passing it on to either their loved ones or to patients:

…the fear … you don't know what you're going to be carrying in and you don't want to be infecting anybody and you don't want to be that person who's the one to blame. (Fiona, Year 2)

Further to the fear of contracting the virus, participants highlighted a concern relating to the absence of a protocol in place identifying what they needed to do should they contract COVID‐19:

If we did get COVID, what's plan B, where are we going to go with regards to being at home and protecting your own family. (Marilyn, Year 3)

Guilt was reported by participants, particularly when others contracted COVID‐19 from them:

Then the week that I did come home I ended up giving everyone COVID and all my brothers had to take off work and then they were down because they had to take work off for two weeks and it was just a hard time. (Anna, Year 2)

During the first wave of the pandemic, nursing students felt frustrated that COVID‐19 testing was not made available to them, which generated worry and uncertainty:

I was worrying that I could have picked it up and I was bringing it around this whole ward and was that going to be my fault? (Geraldine, Year 2)

Some pre‐internship (Year 4) students reported a sense of feeling undervalued for the role they played as part of the multidisciplinary team during the pandemic and concerns were raised about remuneration:

Some days you're thinking why am I even doing this, I'd get more if I was on the PUP (Pandemic Unemployment Payment) payment…sometimes the pay you're just looking at it and this is definitely not worth coming into work and just risking, catching it at work and coming back home and then potentially infecting everybody there in your house. (Willow, Year 4)

Coping strategies during the pandemic

Despite the extra‐ordinary situation in which students found themselves during the COVID‐19 pandemic, their responses demonstrated a remarkable ability to adjust and cope during this time. Strategies for self‐care were identified by students that assisted them cope with the many challenges experienced. Students reported that keeping themselves occupied helped. Others were grateful to have the opportunity to work clinically as HCA's, seeing this as a means of “getting out of the house” and relieve boredom that would otherwise ensue. The overarching support reported as helpful was the support of fellow nursing students and their families.

Keeping busy as a means of coping

Participants identified various strategies to help them cope with difficulties encountered while working clinically during the pandemic:

I just kept myself busy…go for a walk if I needed to, watched too many Netflix series! But it kept me busy and occupied. (Beatrice, Year 3)

In the main, participants expressed gratitude for being in a position to work during the pandemic:

You had that sense that you were helping, and you were useful, instead of just sitting at home. (Catherine, Year 3)

Others were glad of the opportunity to attend clinical placement as a means of relieving the boredom and isolation of staying at home:

I think working in healthcare is definitely a positive because we are getting out of the house two or three days a week, you know we are meeting other people. (Heather, Year 4)

The importance of family, peer and clinical staff support

Family bonds and relationships were fostered as a direct result of the imposed restrictions on the public having to stay at home. During lockdown, students recounted spending time with family as a positive aspect to emerge from the pandemic. It must also be acknowledged that other students on clinical placement made the conscious decision to stay away from family, resulting in students spending long periods of time away from loved ones in an effort to protect them from contracting COVID‐19.

Spending more time with the family was a nice side of things…that's one thing COVID did teach us as well, time is very limited, you're here today, you're gone tomorrow, and you just don't know what's around the corner. So, I value the time I have with my family now…we've got a lot closer. (Marilyn, Year 3)

The overwhelming means of support and coping identified by participants during the pandemic was that of their fellow nursing students. Participants identified the importance of communicating with their peers who were going through the same experience:

It was nice to have someone to talk to in the evenings because it's hard when you're going home with everything that's went on all in your head but then you'd be able to debrief and talk to someone about it, it can help calm you. (Daisy, Year 4)

Digital technology also played a major part in the lives of students as a method of maintaining connectedness and providing support to each other throughout the pandemic:

The other student nurses going through the same thing helped a lot, having that WhatsApp group and occasionally you might see somebody reach out saying, ‘Oh my God is anyone feeling super stressed out about this or that?' And all of a sudden, a whole chain of messages comes saying everyone's feeling the same way so I thought that was very reassuring to know that you're not the only one experiencing that, everyone else is having the same feelings. (Fiona, Year 2)

Students acknowledged the support received from clinical staff particularly by staff nurses (preceptors) who supervised students and from clinical placement co‐ordinators (CPCs) who have the remit of supporting students learning while on clinical placement:

she was the best preceptor I've ever worked with…she was so good to me, and we did a debrief after almost everything, because she knew this was, for both of us actually, we were both working in an environment we'd never been in before. (Nora, Year 3)

the CPCs were a great support for us…especially now, more so than ever, they really do mother you in certain ways, they're just always there, checking in on you…they're always there. (Marilyn, Year 3)

The CPCs in the hospital…are absolutely outstanding in their role. You can tell that they really care about the students, not just professionally but personally. (Sally, Year 1)

Student learning specific to COVID‐19

During focus group interviews, students detailed a number of areas where learning opportunities specific to COVID‐19 occurred. Some students felt that learning occurred because of the highly charged clinical environment and the additional responsibilities given to them. This in turn leads to greater self‐confidence. Students reported learning around areas such as infection control, identifying patient deterioration and communication skills. Despite the uncertainty and unpredictability of the clinical environment during COVID‐19, some students reported great pride in their contribution to patient care.

Infection control

Infection control measures took on a whole new significance for students, healthcare staff and the public like never before. This theme identified the learning that took place specifically related to COVID‐19 while students worked clinically during the pandemic. Responses were varied; however, most students discussed the importance of abiding to infection control measures and carrying out effective hand hygiene in an effort to minimize virus transmission.

This was evidenced by one student who stated “infection control is so important and you cannot wash your hands enough in a day” (Michelle, Year 3).

Students became adept at donning and doffing of personal protective equipment (PPE) and understood the role PPE played in infection prevention and control.

PPE has become second nature to us. (Willow, Year 4)

I learned how important your PPE is and wearing a mask, it really does protect you, and doing your hand hygiene. (Lisette, Year 1)

Sink or swim

Despite working in a highly pressurized and ever‐changing clinical environment, students felt that learning took place because of the additional responsibility afforded to them.

We learned how to deal with high stress situations, we learned a lot of endurance…I think we did learn a lot, to be able to cope with a lot more than we would usually on a normal placement. (Evie, Year 2)

Most students developed a greater sense of confidence, trusting their clinical intuition and instincts because of additional autonomy afforded to them. Students welcomed the additional responsibilities and were glad of opportunities they would not ordinarily have exposure to:

because we were given more responsibility, there was a lot of learning for us…You felt like you were actually making a difference and not just the student nurse…I think that was definitely a great learning experience for us. (Ellie, Year 3)

Similarly, other students further discussed the benefits of having additional responsibility and how this contributed to developing their clinical skills and their overall learning:

I think it's probably the best thing that could ever have happened to us…you are definitely thrown in the deep end more than ever. And I think being thrown in the deep end this year definitely heightened our skills. We were doing more than we'd normally do, you're really getting more involved…it made us more competent overall, because we were doing a lot of things consistently. (Mary Ellen, Year 3)

“Weathering the Storm”

Many students flourished during this time despite the uncertainty and fear experienced by them, and reflected on their experience with a sense of pride in their ability to “weather the storm.” Students reported the pandemic bringing about opportunities that would not otherwise have existed and were grateful for this exposure:

I was struck by the amount of people who asked me ‘do you still want to do it after all this craziness’ and I was like ‘yeah’. If you can weather this storm, you can weather anything…It was an invaluable, whilst scary experience, it was a great learning curve. (Michelle, Year 3)

I think it certainly made me think this is actually what I want to do, in the situations that we were in and how extreme that they were, I said if I can get through this I think we can get through anything. So, I knew there and then that I was certain I wanted to become a nurse. (Mary Ellen, Year 3)

The importance of communication

Students frequently recounted fulfilling the unmet need for support and companionship for patients who were alone in hospital. Students further noted the importance of family particularly for older patients. Owing to visiting restrictions in all healthcare settings, family members were not permitted to visit patients in‐person which had a negative effect on morale and mood for those who were hospitalized:

it did help me learn about care of the elderly and how much their support system really means to them…when they can't have their family coming to visit them. (Fiona, Year 2)

In addition to recognizing the importance of communication with family members, students also noted how effective communication by staff positively impacted patients experience. Communication skills are an inherent part of every undergraduate nursing curriculum and such skills are developed over time. Students acknowledged that having the time to talk to patients enhanced their communication skills. Additionally, having effective role models was also seen as facilitator of learning specifically how to communicate with patients and families:

I definitely did a lot more talking on this placement than I did in my previous placement. I feel that when patients are upset about something, they're not really talking to their families anymore, they probably talk to me about it and I feel that I've learned how to communicate with people more than I probably would have. (Siobhan, Year 1)

Identifying patient deterioration

Throughout the COVID‐19 pandemic, healthcare professionals including nursing students had to quickly adapt and learn how to provide optimal care for those affected.

You see how fast a patient can deteriorate if they have COVID. They could be fine one minute and the next minute you check again and their oxygen saturations have dropped down to 80% and the whole team is inside the room trying to stabilise your patient. (Willow, Year 4)

Exposure to COVID‐19 patients facilitated development of “intuitive knowing” such as identifying a patient in decline and acting accordingly:

I feel like going with that gut feeling, just reading the patient…you get to know the person and it made me more attuned to going through their readings, are they OK, I just don't feel like they're OK…I just don't feel like they're right, there's something not right. So, being able to say that to your nurse with confidence and being able to read people, I feel like I've gotten better at that…I think that's improved. (Geraldine, Year 2)

Students attained advanced skills caring for COVID‐19 patients which they would not ordinarily have had experience of:

How a patient can deteriorate in matter of minutes, their saturations would just drop…it was like ICU nursing, only in a ward, because there were so many patients, it was probably just a step away from ICU nursing. So, we were kind of doing a bit of both. (Michael, Year 4)

DISCUSSION

Much has been documented in recent months about the challenges experienced by nursing students as a result of the current COVID‐19 pandemic. As a consequence of COVID‐19, and the increased number of people admitted to the acute hospital setting requiring treatment, a responsive and adaptive workforce was required. This research identified many positive outcomes for participants, namely their ability to cope during stressful situations and the subsequent learning consequential to working clinically during the pandemic.

In this study, students reported a sense of self‐doubt of their own competence. Staff shortages added to the anxiety experienced by students as did feeling over‐burdened with their increased workload. Others developed a new‐found confidence in their ability to work outside of their comfort zone and flourished from the affirmation and praise bestowed on them by qualified nursing staff. An increased workload resulted in less available time for staff to supervise students (Ulenaers et al., 2021).

Patient communication was adversely affected with restrictions to family visiting, the wearing of PPE and particularly significant was the wearing of face masks. Reorganization of patient care to minimize exposure to infection coupled with both visiting restrictions and diminished nurse–patient interactions left students believing this was inhumane and sad (Casafont et al., 2021). Similarly, Ulenaers et al. (2021) found that nursing students believed contact with patients remained impersonal due to social distancing and the use of masks which concealed facial expressions. Shah et al. (2020) described the effects that seeing patients die alone had on health professionals. In the current study, students demonstrate huge empathy for their patients with responding students identifying a perceived need to take on the role of family members particularly at end of life so that the patient would not die alone. The value placed on psychological care, and human social interactions were identified by students in this research.

Digital technology played an important role in facilitating communication between patients and their families when visiting restrictions were in place. Digital technology and social networking were also important for students as a means of communication and for remaining connected with each other. Xue et al. (2020) and Wallace et al. (2021) contend that online communication based on electronic information technology can provide a sustainable support for nurses during a pandemic.

Students in this research experienced fear in various forms; fear of the unknown due to the changing global and clinical landscape caused by the pandemic, fear of contracting COVID‐19 and fear of passing the virus on to family and friends. This is consistent with findings of other studies noting nursing students were willing to play their part in the healthcare workforce despite experiencing many negative emotions such as fear, stress and anxiety (Brouwer et al., 2021; Casafont et al., 2021; Martin‐Delgado et al., 2021; Shanafelt et al., 2020). A moral juxtaposition existed for participants with the desire to help and feel useful, coupled with the fear of becoming infected with COVID‐19 and subsequently infecting others. This paradox was also reported by Martin‐Delgado et al. (2021). Participants experienced a sense of collegiality and teamwork which was not as apparent to them in previous times. This was also highlighted by Casafont et al. (2021) who reported students' sense of belonging and value as a result of teamwork during the pandemic.

Nursing students employed various coping strategies to help deal with stressors brought on by working clinically during the pandemic. Strategies for self‐care included keeping occupied, interactions with family and friends where permitted and peer support was especially important. Nursing students as a cohort globally may be inherently more vulnerable to psychological distress (Brouwer et al., 2021; Mitchell, 2018; Turner & McCarthy, 2017). Aslan and Pekince (2021) report that nursing students perceived a moderate level of stress during the COVID‐19 pandemic. Additionally, the pandemic brought it with a new reality and changes to the context of traditional clinical training. A recent study by Eweida et al. (2020) reported the majority of intern‐nursing students recorded high levels of psychological distress. Faced with these challenges, nursing students in this research emphasized the importance of self‐care, fostering family bonds and relationships. Additionally, a major mechanism of coping for them was the overwhelming support they received from fellow nursing students. This finding broadly supports the work of other studies in this area (Ali et al., 2020; Slonim et al., 2015). Brouwer et al. (2021) contend that students who reported higher scores on self‐care practices had lower psychological distress scores. Consistent with the literature, findings from this research identified the importance of nursing colleges and hospital administrations offering psychological support and training to students to promote and enhance resilience for future events (Aslan & Pekince, 2021; Pearce, 2021).

Many positives emerged from this study such as the way students benefitted from novel learning opportunities afforded to them as a consequence of the pandemic. The value placed on adhering to infection control policies and procedures was apparent as well as the important role healthcare staff assumed communicating with hospitalized patients. This was particularly apparent with the absence of family visits for patients. Spanish nursing students equally welcomed opportunities to learn, acquisition of new competencies and enhanced communication skills from working clinically during the pandemic (Martin‐Delgado et al., 2021). Students' learning and confidence were enhanced due to the unprecedented nature and immediacy of the situation they found themselves in, affording them unique opportunities to learn and use their initiative (Newell, 2020).

Limitations

The sample for this study was homogenous, from one‐third level educational sector and mostly female; therefore, the findings should be cautiously interpreted.

The study reflects the experiences of general nursing students who worked in an acute hospital setting during the pandemic. The experiences of students from other nursing backgrounds or from those who completed clinical placement in a community setting may differ.

CONCLUSION

This study describes the experiences of undergraduate general nursing students who worked clinically during the COVID‐19 pandemic in Ireland. Due to the dynamic and unique nature of this research, there is a dearth of existing literature; therefore, new knowledge has been generated from this research. The clinical placement experience was dramatically altered due to restructuring of hospitals or closure of non‐acute clinical settings. Students faced varying adversities while in the clinical setting either in their role as a nursing student or as a healthcare assistant. Challenges such as an increased workload, fear of contracting the virus and taking on novel and additional roles were revealed. However, students remained undeterred and reported their experiences as a source of personal and professional growth and benefitted from the learning opportunities afforded to them. Emerging research focusing on nursing students' experiences of the pandemic identifies that the adversities and challenges faced by this cohort are not unique to Ireland but are a common phenomenon irrespective of the country.

RELEVANCE TO CLINICAL PRACTICE

The results of this study demonstrate the key role nursing students play as part of the multidisciplinary team. Despite facing professional and personal adversities, results further emphasize that with the appropriate level of clinical supervision, encouragement and nurturing from qualified staff nurses, students are willing and able to competently deliver effective and compassionate patient care.

Given the challenging situations nursing students found themselves in during the pandemic, findings from this research can assist professional nurse organizations and nurse educators to design effective education in resilience and stress management, thus ensuring that future nurses are better equipped to react and respond to similar events. While De Poy and Gitlin (2020) suggest that usefulness in research is a subjective criterion, this study is indeed transferable and useful in a national and international frame of reference to both professional nurse organizations and nurse educators.

AUTHORS CONTRIBUTIONS

L. Dempsey and L. Gaffney conceived and designed the study. L. Dempsey, L. Gaffney and S. Bracken drafted the manuscript. All authors contributed to data collection, analysis and interpretation of the data, reviewed the final manuscript and hold themselves jointly to the content.

FUNDING INFORMATION

This study received funding from the Learning and Teaching Unit, TUS to assist with interview transcription costs and dissemination of findings.

CONFLICT OF INTEREST

None.

ETHICS APPROVAL STATEMENT

The study obtained ethical approval from the Research Ethics Committee at TUS. Participants wereinformed about the purpose of the investigation and were ensured that all data obtained would remain anonymous and confidential.