Perspectives: Nursing students and COVID-19: challenges and coping strategies.

We are writing this Perspectives piece from our position as educators of nurses and nursing students based in India in the hope that exposing some of the challenges we faced as educators, students and nurses, and the coping mechanisms we used, helps others during this ongoing pandemic. As readers will know, India has recently gone through a crushing second wave of COVID-19 which generated a great deal of fear amongst the public and healthcare workers, and now may well be entering further waves. During the first wave, student nurses were no different to others in their feelings of panic, despair and uncertainty. In order to help them, we established a student counselling team and crafted our teaching to enhance students’ knowledge and skills related to caring for people and preventing COVID-19 as our own knowledge grew. In this Perspectives piece, we hope to tell some of that story with the help of student’s voices.

Reducing fear during COVID-19

After our first COVID-19 wave, in the month of February 2021, due to decreased numbers of cases, educational institutions reinstated nursing students' face-to-face clinical experiences. As educators, we knew this was not an easy time for students and this was confirmed in a study by Aslan and Pekince (2020) which showed that 68.1% of students were worried about becoming infected with COVID-19. This unease was heightened by the feelings of many frontline nurses who would act as supporters and role models for students. As one might expect, Huang et al.’s study (2020) showed that frontline nurses had higher levels of anxiety, fear, sadness and anger than nursing students. Our experiences and the research evidence clearly indicated a need to proactively help our students return to their clinical practice in a safe and supported way.

To enable this and to de-escalate students’ fear and anxiety, students were informed to engage in a calming activity like deep breathing, mindfulness meditation, reading or going for a walk, maintain social connection, talk to others and develop new routines. They were also instructed to have enough sleep, eat healthy foods, practise good hygiene and focus on facts rather than fears. In case of any health issue or emotional concern, they were to inform the mentor and programme lead. All necessary preventive measures, such as PPE (facial mask, gloves, impervious gowns and eye protection), were made available to the students. Before sending students to the clinical practicum, they were fully briefed about regular hand hygiene practises and proper use of PPE kit while doing procedures. Students were encouraged to ask questions to deal with their fears of uncertainty related to the pandemic. Students were also informed of the procedures that would occur if during their clinical postings they were found to have COVID-19, we reassured them that during their quarantine and illness we would continue to support them physically and psychologically.

Challenges during COVID-19 placements

Nursing students faced challenges in their clinical experiences at the end of first wave. Students had to deal with many obstacles in carrying out assessments and care of patients not only because of their constant fear of infection but because the protective precautions they had to take made every interaction so much more difficult. Additionally, a few students had skin problems because of frequent use of hand rubs and extensive hand washing. During the second wave in the month of March 2021, students were once again retracted from their clinical practicum and, the whole curriculum was transformed to a virtual delivery. This brought with it a new kind of strain for students as they dealt with anxiety and stress related to their sudden loss of face-to-face clinical contact with patients and their families.

Whilst we knew that long-term social isolation from usual contacts can be detrimental to one's mental health, we knew little about the professional isolation felt by students as they took on their peripheral, virtual role of learning at a distance. As the pandemic progressed, it became clearer that some nursing students faced growing challenges in forming a professional identity (Shun, 2021) and our students experienced similar deficits. Nursing students’ reduced hands-on experience during the months of the pandemic generated a fear of unpreparedness and an anxiety related to dealing with challenges as a graduate nurse. Adapting to dramatic changes, for example, no-campus movement, less peer interaction and no participation in direct patient care was very challenging for nursing students, especially as these changes were in addition to restrictions faced by the rest of the population. In addition, this new way of learning and interacting affected more than just nursing students as it impacted on entire multi-disciplinary teams. These new learning approaches and minimal interactions heightened the already present uncertainties and fears of everyday living at that time which were generated by the media and very natural fears for one’s own and one’s family’s health (Mertens et al., 2020).

Sonam Y experienced moderate stress as a student nurse. ‘My stress levels were affected by watching the news, thinking about the risk of infection, and the constraints in campus. To minimise our stress levels, the institution provided us with up-to-date information regarding the pandemic, as well as training on how to prevent infection transmission, using protective equipment and ensuring the best hygiene for ourselves and others.’

Supporting physical health

The educational institutions in India took all preventive measures available to keep nursing students safe. PPE was provided to those engaged in clinical practice. Nursing students who were infected were quarantined on campus with all basic facilities and care. Institutions also instigated separate teams to keep track of all nursing students with a history of infection exposure and who showed signs of infection and referred them to a physician for consultation and treatment as soon as possible. Also, students with pre-existing medical conditions who contracted the virus were advised to see a doctor immediately to determine their treatment options. Enquiring about the food, water and hygiene needs of students was also critical to our support as was recommending various exercise regimes to ensure that physical activity was maintained (Lopez-Valenciano et al., 2020). Although we always provide pastoral support and advice, none of these processes were ‘standard’ in our previous educational approaches – students and teachers had to adapt how they worked very quickly. All the students who tested COVID-19 positive were added to a WhatsApp group and were contacted about their health status.

Supporting mental and emotional health

The pandemic has the potential to affect students physically, academically, financially and psychologically. A study of the mental health of undergraduate students in New Jersey found that the COVID-19 pandemic is making a significant negative impact on mental health of college students. Anticipatory efforts to support the mental health and well-being of students were needed (Kecojevic et al., 2020) and so we drew on several research studies about COVID-19-related mental health challenges in students to determine the most effective interventions to identify vulnerable students and to plan for acute and long-term psychological services to control and reduce the burden of psychological problems (e.g. Villani et al., 2021). Students were asked to contact the student counselling team regarding psychological issues arising during this time and we enabled frequent online class meetings so they could connect and interact with one another, despite their social distancing, to express their opinions and struggles and gain mutual support and help. We offered mental health appointments with the option of anonymity. In addition, we implemented a virtual mentorship programme to avoid isolation and make more collaborative relationships with students. All in all we made every effort to safeguard our nursing students’ mental health with an effective plan to support their wellness and education (Wang and Zhao, 2020).

E-education

Nursing education has been impacted drastically due to the COVID-19 pandemic in India and globally (Hsieh et al., 2020). All countries have required preventive interventions in line with disaster preparedness. During lockdown, nursing education platforms transferred to virtual from conventional methods exposing many problems for students such as poor internet connection, inadequate resources for accessing online platforms, extra expense and unreliability. These factors have influenced the education delivery systems used by nursing students. Since the early lockdown in 2020, nursing programmes in India have adopted a simulation training approach away from the clinical environment to enable students to increase their clinical competency and skills (Drake et al., 2020) and to have some certainly of continuity of practical experiences. We have used scenario-based simulation training to enhance clinical learning and reduce clinical stress among students.

We have found, as has Ilankoon et al. (2020) that the major impacts of COVID-19 on nursing education are challenges in clinical practice, disturbances and frequent changes to academic plans, learning gaps around what was previously expected and conventional before the pandemic, lack of resources and knowledge related to online learning and undertaking clinical assignments.

Inbarasi, like many students was ‘withdrawn from the clinical practicum, which affected our clinical skills, and there was rapid transition from traditional education to e-learning. I experienced concerns such as a lack of privacy and connectivity issues. During the crisis though our faculty understood and supported us. As time passed E-learning and communication were streamlined’.

Ilankoon et al. (2020) recommended that nursing education institutions should be encouraged to provide materials and support with resources to the students who belong to low income families, to lessen any discriminatory obstacles to their learning. Many institutes have chosen simulation training activities to enhance students’ knowledge and skills, and this has been found to help.

Some more senior nursing students remained in clinical practice during lockdowns to accomplish their clinical requirements and build their experiences. Such students used all preventive measures available and provided a much valued physical task force during the earlier months of the pandemic. All theory for these students was provided through online platforms. These early students completed their required clinical hours and examinations in accordance with their pre-planned schedule. However, this year, practical examination patterns have been changed due to the longevity of the pandemic and the need to conduct practical assessments in the simulation-based laboratory with virtual oral examinations.

Supporting a sense of value, self-confidence and competency

During this pandemic, all nursing personnel including nursing students played a vital role in the management of COVID-19 patients. During the first wave of the disease, health education messages were disseminated to the public with the help of nursing students. In the second wave of this disease, senior nursing students were posted in COVID-19 units to help to give physiological and psychological care to patients. In many institutes in India, senior students were involved in telehealth services too. Nursing students were sent into the community as part of an awareness campaign using booklets, videos and direct communication.

Sonam A found ‘It was the most difficult time for everyone. But being a nursing student, away from clinical practice, was the most challenging aspect of learning. However, over time, the flexibility of studying online has allowed me to better manage my time and find a balance. I believe studying during the pandemic has equipped me with the skills to navigate effectively in the new normal world of work. I am fortunate enough that my mentor has provided me with emotional and psychological support throughout the duration of COVID-19. We also had a virtual counselling session’.

This was our first experience of a pandemic; it taught us a lot and continues to do so as we mitigate the pandemic’s negative effects. So far, we have coped with various crises and recovered with a strong sense of obligation and a better awareness of the effects a pandemic can have on individuals as well as our education system. We were able to close gaps in the clinical arena with high fidelity simulation techniques which resulted in positive reinforcement of learning. We also worked collaboratively to assure the quality of life for students in terms of mental health, advising about getting enough sleep, maintaining emotional stability and ensuring effective communication. We now believe that if a pandemic occurs in the future, we will be able to deal with it more readily.

Our students, as in other countries, have helped to fill gaps in the workforce. As they gained confidence and felt supported they came forward with energy and enthusiasm to join a strong, sensitive and compatible nursing community united in their work during this pandemic.