COVID‐19 and student nurses: A view from England

Abstract

Jackson et al. (2020) have recently described the extraordinary times we face as a result of the COVID‐19 pandemic. As we write, the number of cases and the associated mortality continues to rise. In the United Kingdom (UK), a number of “Nightingale Hospitals” have been constructed within large arenas. Clinical staff who have recently left National Health Service (NHS) are being asked to return to practice to support the rapidly escalating numbers of patients, and nursing students from year two of their degree programme onwards are being asked to opt‐in to an extended placement working to further bolster the numbers of care staff available. This editorial has been written by academics and nursing students from a University in a large city the centre of England, and a senior member of the executive nursing team at a large NHS Trust. At the time of writing (April 2020), the COVID‐19 pandemic is thought to be reaching a peak in the UK and unprecedented requests are being made of our student nurses. Nursing students have been largely unheard in the discussion around COVID‐19, and we wanted to create a space for students to speak and be heard; therefore, the co‐authored content contains some direct quotes from the students. The nursing students are following a 3‐year programme that will culminate in the award of a bachelor's degree and registration with the UK Nursing and Midwifery Council (NMC), conferring the right to practice as a registered adult, children's or mental health nurse. The NMC requires that nursing students undertake a minimum of 2,300 hr of theory and 2,300 hr of direct patient contact. Students are not paid for these compulsory hours of clinical practice. While in the clinical environment, student nurses are closely supervised by registered nurses and must demonstrate appropriate knowledge, skills and attitudes. Students must pass all clinical placements and theoretical assignments to complete their degree. In the UK, the past 2 weeks have seen a surge of support from the general public for healthcare professionals in the “front line” who are caring for patients and putting themselves and their families at risk during the COVID‐19 pandemic. University campuses across the UK have closed their sites and moved their teaching and assessment online to help slow down the rate of infection. The most junior nursing students have had their clinical placements postponed due to an imminent shortage of supervisory staff and rapid changes within the clinical environment. Student nurses in years two and three of their programmes have been asked by Health Education England (HEE) to sign up to undertake extended placements. HEE is a public body charged with overseeing the training of the health service workforce of the future. The students who take up the opportunity to undertake an extended placement will be remunerated in line with the salaries of nursing care assistants. Students will be deployed to health and social care organisations (Health Education England, 2020). The term “deployment” has been carefully chosen to describe the hybrid status of both a student and an employee. As such, both the NHS organisation and the Higher Education Institution (HEI) share a duty of care to students. Students who do not wish to undertake these extended placements will follow a “theory‐only” route for the foreseeable future, deferring their clinical placements. This will mean that they must “catch‐up” on required practice hours later, likely to lead to an increased pressure on the students and on the clinical areas, which have been struggling to build capacity for student learning for some time (Taylor, Angel, Nyanga, & Dickson, 2017). Students who wish to undertake the extended placement can opt to do so from their homes if they cannot or do not wish to stay in their University accommodation. This has been a period of rapid change with the need for close working between health services, government agencies and educational providers, all of which will have a different perspective on the benefits and risks to students of these options. Discussions between academic and student nurses have raised some key issues: professional identify, a rare opportunity to learn, frustration when the opportunity is not available for some, fear and a desire to protect oneself and others, and a sense about feeling undervalued and unrewarded outside of the pandemic induced change in their status. Professional identity is important to nurses. There is an intrinsic reward in being a nurse that for some is linked to the notion of nursing as a vocation or a calling, and many students describe this as a key driver in their choice of career (Eley, Eley, Bertello, & Rogers‐Clark, 2012). In our virtual interviews with applicants to our nursing programmes conducted recently, there has also been a sense that the pandemic and response to nurses by the public has positively reinforced their choice of career. I perceive nursing to be a varied, honourable vocation, in which you only pursue if you have a strong passion for helping individuals through their toughest times in their lives. Some current nursing students considered the request to undertake an extended placement to fulfil that calling: I'm going to be undeniably doing something useful which is a huge part of why I went into nursing This sense of reward is reinforced by the attitudes of friends and family, who expressed pride in them for becoming nurses and valued nurses and nursing: My friends and family have always stood by my career choice and have now shown how proud they feel to know that I am part of this amazing medical team and that I know those amazing nurses and doctors who are currently “on the front line” trying to treat this pandemic. I would not be less inclined to do this job if my friends and family felt it was a less valued career The pandemic and attendant need for increased numbers of nursing staff has provided those who have the choice to go with an opportunity to do something that would not normally be available. Students expressed a sense of being part of history, learning new things and stepping up to a challenge that will be personally fulfilling as well as professionally worthwhile. However, there are those who cannot take the “opportunity” and this was difficult to deal with, generating a sense of failure. I was one of the people the NHS identified as “high risk”. When I received [the news] I was devastated, I really wanted to help and do my bit in the pandemic, but this now seemed impossible. I knew that to protect myself, my patients and my colleagues it was of course the sensible thing to do to not complete my placement. However, this did not stop me feeling helpless at home. Every time I watched the news and saw the appreciation nurses got, I just wanted to be involved. I knew I could help and make a difference but was unable to. On Thursday evening I stood at the window and clapped for the NHS. I was proud of my colleagues, but I couldn’t help feeling downhearted as I didn’t want to be stood in the window clapping and instead wanted to be at the hospital helping children and families through the hardest time in their lives! I am feeling anxious about the decision we are having to make. With regard to my situation, I am not going out to placement now due to my medical conditions. It makes me feel so disheartened knowing that I am not helping my colleagues, and am hoping that when back in practice, I can continue to help in any way I can. There are also students who have chosen not to undertake the extended placement. They have expressed how pressure has been brought to bear from friends and family about the risk of contracting the virus. This is particularly pronounced in students who have underlying health conditions such as asthma. Even when a health condition makes a student vulnerable, for some the decision to defer placement is not easy. In the beginning, despite knowing that asthma may be an underlying condition that could put me at more risk, I convinced myself into thinking I was ultimately being selfish and cowardly for thinking that way as I know asthma is a very common condition and I felt like I'd ultimately fail myself if I gave up and went home because of it. Further, there are those who feel a sense of anxiety or fear about the nature of the nursing care they will be undertaking. They appreciate the likelihood of working with severely ill patients and those who are terminally ill. Even with educational preparation and good levels of support, this is challenging for most students (Ranse, Ranse, & Pelkowitz, 2018) and it is going more difficult in a care situation where supervision is probably going to be lighter than normal despite the best efforts of more experienced staff. Students express concerns about causing harm to patients because of reduced levels of supervision. There is a concomitant fear that this could ultimately and in the worst cases result in loss of their future career too. The dissonance between self‐protection, or protection of those you care for, and the drive to “do your bit” was one of the findings in a qualitative study conducted during a previous flu epidemic (Slettmyr, Schandl, & Arman, 2019). This dissonance is heightened because of highly visible public support for those on the “front line.” There is a sense that appreciation is a reward given only to those who put themselves in danger. Students have long campaigned for better recognition for the work they do in the NHS. They feel that they should be paid for the care work they do while on clinical placement and feel that the payment that they are going to get on the extended placement is an indication that they are being valued now in a way they were not before. Proud but undervalued…. But everyone will say they love the NHS, that it's wonderful thing but people won't recognise the harm done to it unless it's literally selling off a hospital. In the same way people will talk about what wonderful work nurses do, how we're angels… but don't demand a pay rise, don't say hey if we're so valuable maybe there should be more of us? and we should have better condition? Because that's mercenary not caring The students are worried about completing their programmes on time and being able to register to practice as a nurse. Newly qualified nurses in England are given a period of preceptorship in the first few months in role to consolidate their learning, acquire further skills and get vital support. Preceptorship is seen as vital in retention of newly qualified nurses (Taylor, Eost‐Telling, & Ellerton, 2019). It is also a period of socialisation where students transition to newly qualified status and review their values and identity, aligning them with the organisation (Hunter & Cook, 2018). Final year students undertaking an extended placement will not have the usually clearly delineated transition from student to qualified nurse and organisations and there is a risk that poor support could increase the numbers who leave the profession early. For year 2 students, there are fears about the pressure to catch‐up on hours during the final year of their programme. For all students, there is a loss of academic time during the extended placement, which locally has been agreed to be one day per week for all students. For some, this carries with a fear of not being able to achieve their best in academic work now or later. I'm someone who has struggled to write work during placement as I find it hard to focus on my work during my time off; I worked hard to get the grades I got and I decided that I can always catch up [clinical] hours later and it would make me feel better if I could do my best on my dissertation and assignments Nurse education is a time for many to enjoy student life, building friendships and experiencing independence for the first time. Students who remain at the campus to work within the hospitals are facing isolation in their shared accommodation as other University students have already gone home. For these students, their extended placement means an extended time away from family and friends who provide a vital support network, needed now more than ever, as they come face‐to‐face with the realities of working in the acute health environment during the pandemic. I’m scared to do an extended placement because it might mean being isolated from my boyfriend and friends who are my biggest support network. Working should be balanced with fun & support. Without that balance I am worried about feeling depressed. This pandemic offers some students rewards and comes with risks and costs. There is a risk that the decision to go onto an extended placement is the wrong one for some. Their perception that offering to help is the right thing to do, the sense of failure caused by being unable to do that, and the costs financially and for their future learning demonstrates the complexity of the factors that they are currently balancing. It is vital that whatever decision these students make, either to go into practice, or to follow the theory‐only route, that they are fully supported in their decision, and not judged. There is evidence through social media that students who have chosen to take the theory‐only route are perceived to lack the courage required to be a nurse. So, very early in career these students are being asked to make potentially the most challenging and difficult decision they have ever had to make, and it is imperative that they choose carefully, and according to their personal and family circumstances and commitments. 2020 is Florence Nightingale’s bicentennial year, designated the Year of the Nurse and Midwife by the World Health Organization. How apposite in the past few months. This pandemic has reflected the sheer determination, bravery and compassion of nurses across the country. From a student nurse’s perspective this has been inspirational. I have never been prouder of the profession that I have chosen to pursue, and I am proud that I will be part of the NHS. We must ensure that students are making a free choice. The student co‐authors of this editorial have shared how they are weighing up a multitude of factors that will influence their decision‐making. Individual students will be weighing many dissonant factors including their desire to help, their need to earn, their health, the health of their families, the fear of lighter‐touch supervision, anxiety about the quality of the learning experience and a desire to complete their programme on time in the least stressful way possible. Regardless of the decision each individual student makes, health organisations and educational providers have a duty of care to ensure the physical and psychological safety of nursing students who are stepping up to the fight against this pandemic. At the time of writing, many students have decided to opt‐in to the extended placement, and health and education organisations are creating networks of support for them in what we know will be a challenging time.