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Experiential Learning Program to Strengthen Self-Reflection and Critical Thinking in Freshmen Nursing Students during COVID-19: A Quasi-Experimental Study
research-article
Publication date (Electronic):
28 July 2020
Publisher:
MDPI
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Abstract
This article focuses on the unique needs and concerns of nursing educators and nursing students in the face of the COVID-19 pandemic. During social distancing, interacting with other human beings has been restricted. This would undermine the experiential learning of nursing students. Hence, it is important to develop and evaluate an experiential learning program (ELP) for nursing education. A pre-test and post-test design were used. The study was conducted in a university in Central Taiwan. A total of 103 nursing students participated in the study from February to June 2019. The study intervention was the experiential learning program (ELP), including bodily experiences and nursing activities with babies, pregnant women, and the elderly. After the intervention, the students completed the self-reflection and insight scale (SRIS) and Taiwan Critical Thinking Disposition Inventory (TCTDI) as outcome measures. An independent t-test showed that there was a significant difference between pre-test and post-test in both SRIS and TCTDI ( p < 0.01). The Pearson product–moment correlation analysis showed that SRIS and TCTDI were significantly positively correlated ( p < 0.01). ELP has a significant impact on the self-reflection and critical thinking of first-year nursing students, which can be used as a reference for the education of nursing students. During these turbulent times, it is especially vital for faculties to provide experiential learning instead of the traditional teaching concept.
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Severe Outcomes Among Patients with Coronavirus Disease 2019 (COVID-19) — United States, February 12–March 16, 2020
Stephanie R Bialek, Ellen Boundy, Virginia Bowen … (2020)
On March 18, 2020, this report was posted online as an MMWR Early Release. Globally, approximately 170,000 confirmed cases of coronavirus disease 2019 (COVID-19) caused by the 2019 novel coronavirus (SARS-CoV-2) have been reported, including an estimated 7,000 deaths in approximately 150 countries ( 1 ). On March 11, 2020, the World Health Organization declared the COVID-19 outbreak a pandemic ( 2 ). Data from China have indicated that older adults, particularly those with serious underlying health conditions, are at higher risk for severe COVID-19–associated illness and death than are younger persons ( 3 ). Although the majority of reported COVID-19 cases in China were mild (81%), approximately 80% of deaths occurred among adults aged ≥60 years; only one (0.1%) death occurred in a person aged ≤19 years ( 3 ). In this report, COVID-19 cases in the United States that occurred during February 12–March 16, 2020 and severity of disease (hospitalization, admission to intensive care unit [ICU], and death) were analyzed by age group. As of March 16, a total of 4,226 COVID-19 cases in the United States had been reported to CDC, with multiple cases reported among older adults living in long-term care facilities ( 4 ). Overall, 31% of cases, 45% of hospitalizations, 53% of ICU admissions, and 80% of deaths associated with COVID-19 were among adults aged ≥65 years with the highest percentage of severe outcomes among persons aged ≥85 years. In contrast, no ICU admissions or deaths were reported among persons aged ≤19 years. Similar to reports from other countries, this finding suggests that the risk for serious disease and death from COVID-19 is higher in older age groups. Data from cases reported from 49 states, the District of Columbia, and three U.S. territories ( 5 ) to CDC during February 12–March 16 were analyzed. Cases among persons repatriated to the United States from Wuhan, China and from Japan (including patients repatriated from cruise ships) were excluded. States and jurisdictions voluntarily reported data on laboratory-confirmed cases of COVID-19 using previously developed data collection forms ( 6 ). The cases described in this report include both COVID-19 cases confirmed by state or local public health laboratories as well as those with a positive test at the state or local public health laboratories and confirmation at CDC. No data on serious underlying health conditions were available. Data on these cases are preliminary and are missing for some key characteristics of interest, including hospitalization status (1,514), ICU admission (2,253), death (2,001), and age (386). Because of these missing data, the percentages of hospitalizations, ICU admissions, and deaths (case-fatality percentages) were estimated as a range. The lower bound of these percentages was estimated by using all cases within each age group as denominators. The corresponding upper bound of these percentages was estimated by using only cases with known information on each outcome as denominators. As of March 16, a total of 4,226 COVID-19 cases had been reported in the United States, with reports increasing to 500 or more cases per day beginning March 14 (Figure 1). Among 2,449 patients with known age, 6% were aged ≥85, 25% were aged 65–84 years, 18% each were aged 55–64 years and 45–54 years, and 29% were aged 20–44 years (Figure 2). Only 5% of cases occurred in persons aged 0–19 years. FIGURE 1 Number of new coronavirus disease 2019 (COVID-19) cases reported daily*,† (N = 4,226) — United States, February 12–March 16, 2020 * Includes both COVID-19 cases confirmed by state or local public health laboratories, as well as those testing positive at the state or local public health laboratories and confirmed at CDC. † Cases identified before February 28 were aggregated and reported during March 1–3. The figure is a histogram, an epidemiologic curve showing 4,226 coronavirus disease 2019 (COVID-19) cases, by date of case report, in the United States during February 12–March 16, 2020. Figure 2 Coronavirus disease 2019 (COVID-19) hospitalizations,* intensive care unit (ICU) admissions, † and deaths, § by age group — United States, February 12– March 16, 2020 * Hospitalization status missing or unknown for 1,514 cases. † ICU status missing or unknown for 2,253 cases. § Illness outcome or death missing or unknown for 2,001 cases. The figure is a bar chart showing the number of coronavirus disease 2019 (COVID-19) hospitalizations, intensive care unit admissions, and deaths, by age group, in the United States during February 12– March 16, 2020. Among 508 (12%) patients known to have been hospitalized, 9% were aged ≥85 years, 36% were aged 65–84 years, 17% were aged 55–64 years, 18% were 45–54 years, and 20% were aged 20–44 years. Less than 1% of hospitalizations were among persons aged ≤19 years (Figure 2). The percentage of persons hospitalized increased with age, from 2%–3% among persons aged ≤19 years, to ≥31% among adults aged ≥85 years. (Table). TABLE Hospitalization, intensive care unit (ICU) admission, and case–fatality percentages for reported COVID–19 cases, by age group —United States, February 12–March 16, 2020 Age group (yrs) (no. of cases) %* Hospitalization ICU admission Case-fatality 0–19 (123) 1.6–2.5 0 0 20–44 (705) 14.3–20.8 2.0–4.2 0.1–0.2 45–54 (429) 21.2–28.3 5.4–10.4 0.5–0.8 55–64 (429) 20.5–30.1 4.7–11.2 1.4–2.6 65–74 (409) 28.6–43.5 8.1–18.8 2.7–4.9 75–84 (210) 30.5–58.7 10.5–31.0 4.3–10.5 ≥85 (144) 31.3–70.3 6.3–29.0 10.4–27.3 Total (2,449) 20.7–31.4 4.9–11.5 1.8–3.4 * Lower bound of range = number of persons hospitalized, admitted to ICU, or who died among total in age group; upper bound of range = number of persons hospitalized, admitted to ICU, or who died among total in age group with known hospitalization status, ICU admission status, or death. Among 121 patients known to have been admitted to an ICU, 7% of cases were reported among adults ≥85 years, 46% among adults aged 65–84 years, 36% among adults aged 45–64 years, and 12% among adults aged 20–44 years (Figure 2). No ICU admissions were reported among persons aged ≤19 years. Percentages of ICU admissions were lowest among adults aged 20–44 years (2%–4%) and highest among adults aged 75–84 years (11%–31%) (Table). Among 44 cases with known outcome, 15 (34%) deaths were reported among adults aged ≥85 years, 20 (46%) among adults aged 65–84 years, and nine (20%) among adults aged 20–64 years. Case-fatality percentages increased with increasing age, from no deaths reported among persons aged ≤19 years to highest percentages (10%–27%) among adults aged ≥85 years (Table) (Figure 2). Discussion Since February 12, 4,226 COVID-19 cases were reported in the United States; 31% of cases, 45% of hospitalizations, 53% of ICU admissions, and 80% of deaths occurred among adults aged ≥65 years with the highest percentage of severe outcomes among persons aged ≥85 years. These findings are similar to data from China, which indicated >80% of deaths occurred among persons aged ≥60 years ( 3 ). These preliminary data also demonstrate that severe illness leading to hospitalization, including ICU admission and death, can occur in adults of any age with COVID-19. In contrast, persons aged ≤19 years appear to have milder COVID-19 illness, with almost no hospitalizations or deaths reported to date in the United States in this age group. Given the spread of COVID-19 in many U.S. communities, CDC continues to update current recommendations and develop new resources and guidance, including for adults aged ≥65 years as well as those involved in their care ( 7 , 8 ). Approximately 49 million U.S. persons are aged ≥65 years ( 9 ), and many of these adults, who are at risk for severe COVID-19–associated illness, might depend on services and support to maintain their health and independence. To prepare for potential COVID-19 illness among persons at high risk, family members and caregivers of older adults should know what medications they are taking and ensure that food and required medical supplies are available. Long-term care facilities should be particularly vigilant to prevent the introduction and spread of COVID-19 ( 10 ). In addition, clinicians who care for adults should be aware that COVID-19 can result in severe disease among persons of all ages. Persons with suspected or confirmed COVID-19 should monitor their symptoms and call their provider for guidance if symptoms worsen or seek emergency care for persistent severe symptoms. Additional guidance is available for health care providers on CDC’s website (https://www.cdc.gov/coronavirus/2019-nCoV/hcp/index.html). This report describes the current epidemiology of COVID-19 in the United States, using preliminary data. The findings in this report are subject to at least five limitations. First, data were missing for key variables of interest. Data on age and outcomes, including hospitalization, ICU admission, and death, were missing for 9%–53% of cases, which likely resulted in an underestimation of these outcomes. Second, further time for follow-up is needed to ascertain outcomes among active cases. Third, the initial approach to testing was to identify patients among those with travel histories or persons with more severe disease, and these data might overestimate the prevalence of severe disease. Fourth, data on other risk factors, including serious underlying health conditions that could increase risk for complications and severe illness, were unavailable at the time of this analysis. Finally, limited testing to date underscores the importance of ongoing surveillance of COVID-19 cases. Additional investigation will increase the understanding about persons who are at risk for severe illness and death from COVID-19 and inform clinical guidance and community-based mitigation measures.* The risk for serious disease and death in COVID-19 cases among persons in the United States increases with age. Social distancing is recommended for all ages to slow the spread of the virus, protect the health care system, and help protect vulnerable older adults. Further, older adults should maintain adequate supplies of nonperishable foods and at least a 30-day supply of necessary medications, take precautions to keep space between themselves and others, stay away from those who are sick, avoid crowds as much as possible, avoid cruise travel and nonessential air travel, and stay home as much as possible to further reduce the risk of being exposed ( 7 ). Persons of all ages and communities can take actions to help slow the spread of COVID-19 and protect older adults. † Summary What is already known about this topic? Early data from China suggest that a majority of coronavirus disease 2019 (COVID-19) deaths have occurred among adults aged ≥60 years and among persons with serious underlying health conditions. What is added by this report? This first preliminary description of outcomes among patients with COVID-19 in the United States indicates that fatality was highest in persons aged ≥85, ranging from 10% to 27%, followed by 3% to 11% among persons aged 65–84 years, 1% to 3% among persons aged 55-64 years, <1% among persons aged 20–54 years, and no fatalities among persons aged ≤19 years. What are the implications for public health practice? COVID-19 can result in severe disease, including hospitalization, admission to an intensive care unit, and death, especially among older adults. Everyone can take actions, such as social distancing, to help slow the spread of COVID-19 and protect older adults from severe illness.
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Life in the pandemic: Some reflections on nursing in the context of COVID‐19
In the unparalleled and extraordinary public health emergency in which we find ourselves, across the world nurses stand as we always do—at the front line. Nurses everywhere are staffing our clinics, hospital wards and units—in some situations, literally working until they drop, and in some regions, they are doing so while dealing with a lack of essential items. Indeed, we see reports that nurses in many parts of the world are grappling with shortages of much‐needed supplies including personal protective equipments such as masks, gloves and gowns, yet are actively embracing the challenges presented by COVID‐19. As we contemplate the ramifications of this rapidly moving global pandemic, it is clear that the need for nurses has never been greater. In responding to this dire and unprecedented health crisis, as nurses, we are doing what we have been educated and prepared to do. As nurses, we have the knowledge and skills to deliver the care needed in all phases of the illness trajectory, and in reassuring, informing and supporting people within communities who are frightened, worried and wanting to stay well. As we have seen throughout history, nurses are well able to think outside the box, and develop creative and innovative solutions to all manner of problems, conundrums and challenges. However, there remains much about this current situation that is new and frightening. For one is the speed of the spread of COVID‐19. In the fight against COVID‐19, we are working against the clock. The trajectory of this situation is such that in some areas, infection rates are doubling every 24 hr or so, and this is leading to increasing community anxiety manifesting in various ways including panic buying and hoarding of essential supplies. It is clear that this health crisis will not affect everyone in the same way. The very strong public health message is to stay home, and stay safe within that home, in the assumption that everyone has a home that is safe, and within which they have some autonomy. There is some speculation as to whether rates of domestic violence might increase at this time as a result of the extraordinary strain that families face. Poverty is also an issue. It is well known and accepted that those who are homeless and impoverished have many less options when faced with health problems, and the challenges faced by these people will be much greater in this time of pandemic (Tsai & Wilson, 2020). Similarly, people who are captive or imprisoned for any reason, such as in corrections or refugee environments and other similar settings, are particularly vulnerable (Iacobucci, 2020). Older adults are high users of services across primary, secondary and tertiary healthcare settings. Many in this group live with multiple health and social issues that increase their vulnerability, now further exacerbated by the need for social distancing. Older people are known to be at greater risk of calamitous outcomes associated with COVID‐19, and this dire picture is likely to be exacerbated because of the potential for rationing of care based on age, simply because there are not enough ventilators and other life‐saving equipments to meet demand. The risk to older people is greater than to others, and in many countries, limitations on older people activities are in place in attempts to reduce risk of exposure. In several countries, restrictions on visiting nursing homes are in place and people over 70 years of age asked to reduce outings and remain indoors as much as possible to decrease contact with others and reduce the risk of contracting the virus. While necessary, this could put older people at risk of loneliness, isolation and exacerbation of existing problems, and so it is very important that we all look out for older people in our neighbourhoods and provide support, assistance and safe social interaction as required. Nurses are at the forefront in institutional settings such as nursing homes and prisons, with homeless people, and other hard to reach populations and are grappling with the effects of low health literacy, rapidity of change and health information, and a lack of resources to ensure that all know and understand what is required to keep them safe. It is so important that we all support these vulnerable populations and the nurses working within them by advocating for resources including adequate safe accommodation for all. We know from our colleagues that despite being actively engaged in this fight against COVID‐19, in a way that few other professions are, and despite appearing calm and professional; like everyone else, many nurses are also experiencing fear of the unknown and concern for what lies ahead, for themselves, their patients, colleagues and their own families and friends. In addition to being nurses, we are also parents, siblings, friends and partners with all of the worries and concerns shared by most people—providing for and protecting ourselves and our families, and so in addition to caring for patients, the well‐being of our own families weighs heavily on us as nurses at this time. The global nature of this crisis means that while all countries are engaged in the battle against COVID‐19, some have been in the fight for longer and so there is the opportunity to learn from other countries. Indeed, in watching the unfolding horror particularly in Italy, we see just what can (and will) happen in the event that measures such as social distancing, hand hygiene and quarantine are not fully embraced by all in our communities. Earlier this year, Hong Kong was one of the first places in the world affected by the COVID‐19 virus, evoking unwanted memories of the SARS outbreak of 2003 (Smith, Ng, & Ho Cheung Li, 2020). Despite initial fears, the spread of the virus appeared to have been effectively controlled over the last two months through the use of stringent measures, including practice of good personal hygiene, avoidance of group gatherings and implementation of social isolation measures. Indeed, by the beginning of March 2020 some public services in Hong Kong had started to resume normal activity and many people were returning to the workplace. In some part, these successes were due to the excellence of the clinical nursing workforce. We saw some stability in other countries in the same region including Singapore and Taiwan. There was hope that the corner had been turned in the fight against COVID‐19; however, this has turned out not to be the case. Very recently, Hong Kong and several other South‐East Asian countries have started to face the second wave of imported coronavirus infections, with the total number of cases in Hong Kong doubling during this period. The vast majority of these new cases have involved people flying to South‐East Asia from abroad, especially students returning from North America and Europe, where COVID‐19 infection has been escalating. Singapore and Taiwan, which had each taken comfort from seeing new infections taper off in recent weeks, have also seen surges of COVID‐19 cases amongst arrivals in recent days. Health officials from these densely populated countries are now struggling to contain the new cases to avoid any new community outbreaks. A similar picture emerged in mainland China. After some sustained and marked reductions in the spread of the virus, China's National Health Commission have recently announced that all new reported cases were imported from overseas. Despite many people fully recovering from COVID‐19 infection in China, there has been some concern that a new subset of patients affected by the virus may be emerging. There are reports that a handful of the many thousands of people declared cured after treatment have been readmitted to hospitals because their symptoms have returned. At the time of writing, this worrying feature of COVID‐19 infection is only beginning to receive attention by the medical community, but clearly requires close consideration in the ongoing global fight against COVID‐19. Across the world, there are concerns that nursing's capacity to provide care will be stretched by the increased workload and by the number of front‐line nurses that are expected to be affected by COVID‐19. In Australia, authorities are considering various mechanisms such as fast‐tracking return to registration of qualified nurses who may be recently retired and allowing limited registration to people who may be suitable such as internationally qualified nurses. In the United Kingdom, there has also been a call for recently retired nurses to return to practice. Other planned strategies include establishing a COVID‐19 temporary register for nurses who have left the register within the past three years, who will be able to opt into this register. Registered nurses not currently working clinically will be encouraged to consider working within clinical practice, and undergraduate nursing students will be able to opt to undertake the final six months of their programme as a clinical placement. Part of the COVID‐19 temporary register is to include a specific student element for those in the final six months of their preregistration programme and will include details of specific conditions to ensure appropriate safeguards are in place. The fine details are still in development, and there may need to be further measures in what is a continually changing situation. In considering introducing new cadres of nurses, there are also issues around risk, retraining, refreshing and renewing knowledge. While there are some aspects of nursing that may not have changed too much over the years, health is generally a rapidly evolving field and particularly in the current situation. In contemplating returning to direct care giving roles, many retired nurses or others contemplating re‐entry may have legitimate concerns about the real contribution that they could make in the current crises, particularly when considering direct care delivery and technological advancements in practice. It will be necessary to consider carefully any possible risk for nurses returning from retirement, and the potential ways these nurses could meaningfully contribute. This may be in working in quieter areas to free up current staff, and working in roles supporting front‐line nurses. Either way, it will be crucial to have adequate learning and resourcing available to support these new cadres of nurses. However, as we identify innovative ways to provide a nursing workforce during this time of urgency, it is important that whatever we implement is safe and appropriate for staff and for patients. Patient safety is paramount and integral to nursing practice. Nurses generally become nurses because of the desire to help people regain and maintain optimal health, and here, we have a situation where there may be very few options to help those who are seriously ill because of COVID‐19. This inability to save lives will take its toll on those at the front line, both physically and emotionally. As nurses, we know death. We have seen loss of life, and we have borne witness to the pain and the suffering of the dying and the grief of those left behind. For nurses, particularly in environments where the focus is on life preserving, such as emergency departments and intensive care units, death can represent failure, and so is therefore a source of stress and distress for the medical and nursing teams in these settings. We are now in a situation where nurses everywhere are bracing for what really is a tsunami of death. Our colleagues in China and Italy have and are leading the way, and we have seen reports and first‐hand accounts of the distress and exhaustion of our Chinese and Italian colleagues who have been (and are) faced with large‐scale death on a daily basis. All aspects of nursing activity are affected by this pandemic, and healthcare facilities have responded to nursing education student clinical needs in a variety of ways. Some have restricted student presence in their organisations, while others welcome healthy students. Academic nurses have also been quick to modify in the light of the crisis caused by COVID‐19 and many have very quickly moved to online course delivery, including strategising to ensure reasonable student engagement, and making appropriate changes to examination procedures. There is also the need to recognise that many nurses currently enrolled in post‐graduate courses may now have their current studies jeopardised because of cancellation of study leave or other pre‐existing work patterns that can now no longer be guaranteed. Nurse educators and administrators are tasked with ensuring that students meet academic requirements while recognising the current pressures faced by health services and the need for nurses to be able to simultaneously meet the demands on them as nurses, students, parents, siblings, partners and the myriad of other roles that each nurse has to manage in their daily lives. The way this crisis has unfolded has meant that we have all sorts of new challenges in seeking to meet the health needs of our populations. For example, we have situations of cruise ships left sailing from port‐to‐port unable to dock; others inadvertently offloading passengers who are ill and contagious into communities, with health services left to set about tracing crew, passengers and those with whom they have been into contact. We have to prepare for the potential ramifications if COVID‐19 takes hold in very vulnerable populations, such as prisons where it will be very hard to contain because of the proximity of people. There is also the aftermath to consider. Of critical importance will be nurses’ responses to the increased anxiety and mental health needs of the population as well as within the nursing community. These are very difficult times, and the scale of the challenges is unprecedented. Every single one of us has a role to play in supporting and advocating for the health of our communities, and in supporting nurses everywhere. Nurses are the backbone of health systems around the world, and this has never been more apparent than now. Amidst all the uncertainty about the virus and how long it might take before life begins to return to normal, there can be no doubt that nursing and the provision of health care will come out the other side of this pandemic stronger and better prepared to face future challenges. We write these “reflections” in the moment, as the impacts of the pandemic unfold around us daily. We are all living it right now. When it is over, we look back and reflect upon it and with the benefit of hindsight, might make normative judgements regarding what we ought to have done and what might have been best at a certain time. Right now, we all need to be kind to each other (and ourselves) as we grapple with new ways of living and working. We want to thank nurses everywhere for their tireless efforts in this unparalleled health emergency.
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COVID‐19 and student nurses: A view from England
Amelia Swift, Louise Banks, Amintha Baleswaran … (2020)
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.
Author and article information
Journal
Journal ID (nlm-ta): Int J Environ Res Public Health
Journal ID (iso-abbrev): Int J Environ Res Public Health
Journal ID (publisher-id): ijerph
Title:
International Journal of Environmental Research and Public Health
Publisher:
MDPI
ISSN
(Print):
1661-7827
ISSN
(Electronic):
1660-4601
Publication date
(Electronic):
28
July
2020
Publication date
(Print):
August
2020
Volume: 17
Issue: 15
Electronic Location Identifier: 5442
Affiliations
[3
]School of Nursing, China Medical University, Taichung 40402, Taiwan;
lichi@
123456mail.cmu.edu.tw
[4
]Department of Nursing, National Taichung University of Science and Technology, Taichung
404, Taiwan;
chyang@
123456nutc.edu.tw
Author notes
Author information
Yi-Chuan Cheng
https://orcid.org/0000-0001-5742-9631
Li-Chi Huang
https://orcid.org/0000-0003-1152-6596
Article
Publisher ID: ijerph-17-05442DOI: 10.3390/ijerph17155442
PMC ID: 7432080
PubMed ID: 32731648
SO-VID: 86725710-22d3-4ae5-9b03-9f5d3b749734
Copyright © © 2020 by the authors.
License:
Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license ( http://creativecommons.org/licenses/by/4.0/).
History
Date
received
: 26
June
2020
Date
accepted
: 27
July
2020
Categories
Subject:
Article
ScienceOpen disciplines: Public health
Data availability:
ScienceOpen disciplines: Public health