The COVID-19 virus spread rapidly across the globe in 2020, becoming a pandemic before it was designated as such and before hospitals or schools could adequately prepare. Nursing programs were forced to suddenly move to online learning or even close. Nursing students struggled during this chaos, anxious to go to hospitals to help and to continue clinicals, but also sometimes suffering extreme anxiety with the uncertainty of their being able to graduate while dealing with family and other responsibilities. The focus for faculty immediately turned to planning and advocating for the students' continuation of clinicals in this constantly changing environment, which remained uncertain. Even before the current pandemic, anxiety among nursing students has been a concern.

A mixed-method, short survey was administered on-line to learn more about the graduates' emotional reactions, especially their anxiety levels. Twenty-five of 38 students responded to the survey. The aim of this article is to share the responses and lessons learned. As expected, anxiety is high during such crises; providing support, grace and flexibility helps. Transparency, frequent updates, check-ins, and creating a sense of community is essential to help lessen anxiety, as experience and research have shown. Considering student feedback is imperative during this time to help faculty improve our effectiveness and support.

Key words: COVID-19; nursing students; survey; anxiety; clinical.

INTRODUCTION

"Schools closed, economies ground to a halt, and healthcare systems collapsed under the strain of the epidemic." [1] —Regarding the Ebola epidemic 2014-2015 in West Africa

As COVID-19 continues to mandate innovative methods for conducting clinicals for nursing students, it is important to consider student feedback. At the start of the pandemic, clinical was halted and then drastically changed. I wanted to learn more about the students' experiences, verify assumptions and glean any lessons for handling the on-going and future crises from the educational perspective. Encouraging students to reflect on their experiences could also benefit them in processing the traumatic events of their final semester. This Short Communication article summarizes the results of a survey administered to the students post-graduation about their experiences and emotional responses to the pandemic and suggestions for decreasing anxiety and moving forward. It serves as a pilot study for future research into the effects of dealing with such a crisis and ways to ensure successful completion or continuation of nursing school as well as mitigation of the emotional stress. We will continue to review lessons learned during this unprecedented time well into the future.

BACKGROUND

The COVID-19 onslaught in March 2020 caused nursing programs to scramble to move to primarily on-line learning. Some schools had to close, and some students were unable to continue at a time when nurses were desperately needed. California became the first state to issue a stay-at-home order. Classes at California State University (CSU) quickly moved to virtual; faculty spent Spring Break rearranging clinical schedules and assignments. Initially, students could not continue clinical, and there was tremendous anxiety about whether they would graduate, combined with a sense of urgency to help with the crisis. The faculty began meeting almost daily to address the challenges and student concerns. The California Board of Nursing remained mostly silent and held firm on not allowing more than 25% of clinical to be non-direct care until late in the semester [2]. The CSU Chico students were able to graduate, although the situation remained tenuous, uncertain, and changing. Learning about anxiety levels among students, their primary concerns, and their views of faculty response can help schools of nursing know how best to support students.

A study of over 1,000 undergraduate students in various subject areas found that students conveyed that it was difficult to stay motivated, did not get immediate feedback from faculty (as with in-person learning), or the prior level of collaboration with peers [3]. Barton, Murray, & Spurlock called for faculty "to practice patience and leniency with our students, and to support our colleagues suddenly tossed into the virtual environment. It's a time to cocreate a new world order within nursing education…" [4] p. 183) Understanding the students' difficulty in concentrating and the need for flexible deadlines continues. We do not yet know what shape the future of nursing or education will take, as we are still in the midst of the crisis. But we are in it together. Building a sense of community is important; fortunately, our students had been together for four semesters, were close-knit, and knew the faculty. Nursing students have listed social support as the second most important coping strategy pre-COVID-19 [5]. The restrictions of the pandemic severely limited students' direct contact with each other and with their faculty, and their clinicals were with a preceptor, not a group. Nursing students are already used to some isolation from the university community and social life due to the rigor of their studies. Still, isolation increased and contributed to stress and anxiety.

Stress correlates with anxiety levels, and both are relatively high for nursing students under normal circumstances [5, 6]. Onieva-Zafra et al. [5] found that nearly half of students surveyed pre-pandemic rated their perceived stress as moderate, and 25% rated it as high. Yet, in this study, half of the students surveyed were in their first semester, and anxiety or stress levels were higher at the senior level [5]. Results of other studies vary worldwide but show lower moderate to severe anxiety levels [5]. Savitsky et al. [6] reported that nearly 43% of students experienced moderate anxiety levels during COVID-19, but only about 13% reported severe anxiety using standard scales. Still, the need to help students navigate stressful situations and deal with anxiety has never been as important as it is now.

The top three anxieties of nursing students are performance, success, and getting a job after graduation [5]. Concern about all three of these increased for students graduating during COVID-19. And historically, although students may enjoy clinical more than theoretical training, they also perceive it as more stressful [5]. The pandemic brought new fears of getting infected and other concerns such as child care. Validating student concerns are paramount in promoting their mental health, and we are reminded of the importance of fostering healthy coping strategies.

RESEARCH QUESTIONS

Questions in the survey pertained to the anxiety level when students found out that clinical would be cancelled and their greatest fears and regrets, as it was obviously an extremely stressful time. I also wanted to verify what they found most helpful that faculty did and suggestions they had for faculty and administrators.

METHOD

A mixed-method, short survey with five Likert scale questions and five open response questions was utilized. It was administered three months after graduation to allow time for reflection and entry into the job market. The questionnaire was reviewed by the program director and approved by the University Internal Review Board (IRB). There was an informed consent form, and resources were provided to participants in the event that completing the survey caused anxiety. Graduates were invited to participate in the survey via e-mail.

SAMPLE

There were 38 students in the cohort; 25 students responded to the survey, providing a response rate of 65.8%. Most of the students were in their early 20's, with two being over 30. Nineteen students were female, and three were male; 11 students identified as being Caucasian, seven as other races. These statistics accurately represent the cohort's demographics and are typical of the CSU Chico nursing student population.

PROCEDURE

Students completed the survey on Qualtrics.com, which is the survey software used by CSU. The program analysed the data; it has been established as secure, trustworthy, and reliable by the university.

RESULTS

                The focus was on the hospital clinical experience; this clinical is a preceptorship 135-hour leadership experience consisting of 9 12-hour shifts; students make their own schedule with their preceptors. The author coordinates this clinical and taught two of the four sections. One lesson immediately apparent during the crisis was the need to begin clinical earlier in the semester and to assist students in completing their shifts as soon as possible in case such an emergency occurs; the survey confirmed this need. Historically, clinical did not start until week 5 of 15. Six students, or 15.8%, had completed over 90 hours when clinical changed in March. It was difficult for the rest of the students to complete the required hours with the alternate assignments and available clinical sites. Forty-two percent had completed less than 50 hours, and of those, four had completed only 24 hours (2 shifts). The average number of hours completed during the first four weeks of clinical was about 58, or one 12-hour shift per week, which is the usual expectation, however.

As expected, most of the students rated their anxiety level as high. The mean was 3.3, with 4 being extreme. The anxiety level remained high until graduation. Most students stated that the most frustrating experience during this time was missing out on the preceptor experience and clinical as it had been planned, and not being able to finish the semester with the nurse to which they had initially been assigned. One student replied that "information, assignments, [and] placements across clinical groups were not the same, not equal" (two groups were eventually able to return to their original hospitals while two were not). Four students cited the constant changes as increasing anxiety levels. One student stated that "the exciting last semester that we all envisioned was gone." Two replies indicated feeling an occasional lack of communication from professors.

Every student answered the question about the biggest regret, and not being with their preceptor or finishing the intended preceptorship was listed 13 times. Missing pinning was listed 11 times. The students also missed being with their cohort. A few graduates listed feeling "less prepared to be a nurse because of this." As expected, the students' greatest fear was not being able to graduate, which was listed by all of the respondents. One student answered that he was also afraid his parents might die. Ninety percent of respondents indicated that they would still want to continue clinical as originally scheduled despite the risks of the situation. Prior studies have shown that students are reluctant to work in high-risk areas [5]. This was generally not the case with our students.

IMPLICATIONS

Communication and support from faculty is critical at times such as these. Savitsy, Findling, Ereli, and Hendel believed this to be the key method of helping students navigate the difficult time and decrease anxiety. Most students rated the quality of updates from faculty as excellent or good (13 out of 18 responses). The one area with room for improvement was regarding the quality of the alternate clinical assignments (non-direct patient care). The mean was 2.6, where 1 is excellent and 4 is poor; 58.3% of the respondents rated it as "fair." This was not surprising since the students wanted to be at clinical, the assignments had to be created immediately, and most of the alternate assignments were completed independently through the virtual learning program, ATI (Assessment Technologies Institute).

Responses to the question "What did you find most helpful from faculty during this time?" included "quick replies to questions," "faculty's eagerness to help", and “being understanding and transparent." Support was listed several times, including feeling a sense of community and togetherness with the faculty. Frequent updates by faculty were listed six times. Under "additional comments," students were grateful for the support faculty, administration, and staff provided to get them through the semester. Twenty percent commented that it was difficult to find a job after graduation.
 

DISCUSSION & RECOMMENDATIONS

Overall, the students felt that the situation was handled properly and that instructors did all they could to be supportive, and that faculty performed well under the circumstances. Students were grateful for frequent communication and updates but also listed having regular updates as a suggestion. One student wrote, "EXTRA communication and reassurance [are] essential during these types of crises." Another stated that "Meetings where all the faculty and students are present are truly helpful." As the American Association of Colleges of Nursing (AACN) stated in their recommendations to schools of nursing, "we all need to embrace what it means to be an inclusive learning community."(7p. 8) The AACN recommended following the three C's of disaster response: Communication, Collaboration, and Cooperation.

An important lesson from this experience is that additional alternate plans need to be in place before crises occur. This is recommended by the AACN [7]. Faculty met the week before Spring Break and the impending shut-down (as it turned out) to begin planning and reviewing relevant policies. We also practiced PPE donning and doffing with all students.

One of the biggest lessons involved scheduling. Two weeks after the crisis began, one local hospital agreed to take all of our students at various locations, assisting with COVID preparations and screening (previously, only one section of ten students was there). The hospital coordinator had created a spread sheet with all of the available dates, locations, and slots. I posted this schedule on-line with specific instructions regarding signing up for slots, such as allowing those students needing the most hours to have preference. This process did not work, and I received many distressed phone calls. Students were desperate and signing up for more slots than needed; some students could not access the schedule immediately when it was posted. I then had to manage the scheduling for all students and monitor their hours daily. One instructor needs to be in charge of scheduling and tracking clinical hours, which can change daily in this situation.

I also learned that we have to live with the discomfort that such disruption causes and that it cannot be alleviated entirely for the students. It is a delicate balance of providing reassurance and also being honest. Simply checking in and listening is essential, as is allowing students as much control as possible. As this pandemic continues, CSU moved entirely to virtual learning for the Fall 2020 and Spring 2021 semester (except essential clinicals and courses). During the continuing challenges and changes, grit, determination, and resilience are traits students need.

High levels of resilience are associated with lower levels of anxiety [6]. Our graduates are exceptionally resilient, having also gone through the Camp Fire in 2018, the worst fire in California history up to that point, which destroyed a whole town. In September 2020, California experienced an even worse fire season, with local fires coming very close to campus. Hardships do build character, courage, and strength, but the effects of cumulative trauma became apparent. This undoubtedly contributed to our students' high anxiety levels. Still, not a single student expressed ambiguity about their decision to become a nurse, and most of them wanted to go to the hospitals immediately to help. They also conveyed readiness to graduate or enter the workforce early if that was an option.

Although our students were generally satisfied, some specific actions can strengthen student satisfaction with the clinical experience. Virtual clinical activities should include interaction when using case studies and simulation, by meeting as a group (i.e., on Zoom), together with using programs with which students are familiar preferably, such as ATI. Although nursing clinical is different from the classroom, we can incorporate general recommended practices from current research on COVID-19 and on-line learning to help alleviate anxiety. Respond quickly to student questions and concerns. Our students have a private Facebook page for each semester, and they met virtually. I asked them to nominate one or two spokespeople to deal directly with me for daily Q&A's. I also held live sessions, which is recommended [3]. Check-in frequently with each student; phone calls feel more personal than e-mails or texting. Let students know how they are doing in the course. Encourage student collaboration, i.e., with group projects. Have students reflect on their learning [3]; we have students complete weekly journals. Faculty too should spend time reflecting on the learning environment and student responses to end-of-course evaluations.

LIMITATIONS

Although anxiety levels of health care workers have been studied during epidemics, research in this area is limited, especially that which focuses on students' clinical experience. The sample size was small, including only the graduating cohort of one nursing program. This limitation might restrict the scope of the study's purpose of identifying experiences and emotional responses to the pandemic. Also, the survey focused primarily on the clinical experiences and did not encompass the universal experience of moving on-line for all other instruction. Use of a standardized anxiety scale such as described by Julian [8] is recommended for future research, as well as comparing previous levels of anxiety. Generalizations to broader student populations or overall nursing programs are limited.

CONCLUSIONS

Students suffered high levels of anxiety, fear, and frustration during this dangerous and uncertain time. It is essential to promote awareness of the effects of cumulative trauma and the need for support and self-care. We have a peer mentoring program, which is helpful for semesters below the senior level. Training in stress management and resilience is as important as any skill taught in nursing school. Our partners—employers of new nurses—have listed these as their only concerns of recent graduates, not the "hard" skills that may have been missed. We are strengthening individual and community support for our students and looking for ways to move beyond suggesting common coping strategies such as meditation and counselling.

The biggest lesson personally became apparent upon reflecting on my own frustration at spending excessive amounts of time on record-keeping and scheduling—tasks seemingly unrelated to nursing or teaching. Then I realized that I had become a better leader, and I had learned the delicacy and necessity of relaying bad news. I had to be able to do that in a timely way and be supportive of the students. I also became a better facilitator, advocate, and counselor, all important nursing and teaching roles, as is building resilience and community.

This article provided reflections on student and faculty experiences during the beginning of the COVID-19 crisis and provided some suggestions to move forward. While the sample size is small, several lessons can be generalized to other nursing programs and to future disasters. It would be unrealistic to think that such a catastrophe will not happen again. Integrating virtual learning in the present and future will be an on-going process requiring evaluation of its effectiveness. Research and reflection continue and are needed during this time in history and in nursing.

REFERENCES

1. Doctors without Borders. Liberia after Ebola - Learning from the past, preparing for the future. Alert. 2016; 17(4): 3–9.

2. Kirchmeyer K. Order Waiving Restrictions on Nursing Student Clinical Hours. [Internet] 2020. [cited 2021 March 2].

3. Means B, Neisler J. Teaching and Learning in the Time of COVID: The Student Perspective. On-line Learning Journal. [Internet]. 2021 [cited 2021 May 25]; 25.

4. Barton, AJ, Murray, TA & Spurlock DR. An open letter to members of the nursing education community. J Nurs Educ [Internet]. 2020; 59(4): 183.

5. Onieva-Zafra MD, Fernández-Muñoz JJ, et al. Anxiety, perceived stress and coping strategies in nursing students: a cross-sectional, correlational, descriptive study. BMC Med Educ [Internet]. 2020 Dec 1.

6. Savitsky B, Findling Y, et al. Anxiety and coping strategies among nursing students during the covid-19 pandemic. Nurse Educ Pract. [Internet]. 2020 Jul [cited 2021 May 23]; 1; 46: 102809.

7. AACN (American Association of Colleges of Nursing). Considerations for Reopening U.S. Schools of Nursing during COVID-19 [Internet]. 2020 Jul [cited 2020 Sep 13].

8. Julian LJ. Measures of anxiety: State-Trait Anxiety Inventory (STAI), Beck Anxiety Inventory (BAI), and Hospital Anxiety and Depression Scale-Anxiety (HADS-A). Arthritis Care Res [Internet]. 2011 Nov [cited 2021 May 23]; 63 (SUPPL. 11).

PEER REVIEW

Not commissioned. Externally peer reviewed.