key: cord-0718874-o8h3t319
authors: Laczko, Dana; Hodson, Alex; Dykhuizen, Melissa; Knipple, Kelsey; Norman, Kassandra; Hand-Cortes, Paula
title: Nursing Students Experiences’ of Mental Wellness During the COVID-19 Pandemic: A Phenomenological Study
date: 2022-03-11
journal: Teach Learn Nurs
DOI: 10.1016/j.teln.2022.03.002
sha: 1e65d1017dedc8d70b7a50af56a3da0cea50c46e
doc_id: 718874
cord_uid: o8h3t319

INTRODUCTION: Acute psychological stress is commonly experienced by university students as they transition through a new learning environment; however, uncontrolled and long-term stress, such as that experienced due to the global respiratory pandemic, contributes to a severe decline in the physical and mental health of nursing students and decreases their academic success. The aim of this study was to investigate the experience of mental wellness as lived by nursing students and to understand how nursing students were coping with the impact of COVID-19. METHODS: Individual interviews were used as a data collection method in this qualitative study, guided by descriptive phenomenology. Nursing students from two institutions in Western Canada were recruited in the fall of 2020. Interviews with six participants were recorded and transcribed verbatim. Meaning units from the data were transformed into a constituents table which resulted in a rich description of the essence of mental wellness as experienced by participants. RESULTS: Key elements of the experience included: shifting support systems, disconnection, worry, sense of missing out, environmental stress and continual adaptation. The essence of the experience reflected on-going trauma. DISCUSSION: This research highlighted the importance of acknowledging the persistent, collective trauma experienced by students and faculty alike due to the global pandemic. A trauma-informed approach to nursing education, where positive coping is modelled and a safe learning space is provided, will be required going forward.

In the past two years, the world has been immensely challenged with a global pandemic that has disrupted and dismantled normal daily functioning across the globe. Students enrolled in nursing education programs faced disruptions in class schedules, class availability, and clinical practicum experiences. These students may also be facing social isolation, personal illness from the pandemic virus, as well as childcare or relationship disruptions with the potential to increase stress and impact student mental health.

Prior to the pandemic, undergraduate nursing students were already at a higher risk for high levels of anxiety than students in other health care disciplines (Savitsky et al., 2020) .

Nursing students experience stress and anxiety due to exposure to patient suffering and death, difficult interpersonal relationships in a clinical setting, heavy workload, and fear of making errors (Beanlands et al.,2019; Feitosa et al., 2017; Karaca et al., 2019; Savitsky et al., 2020) . It has been well documented that uncontrolled and long-term stress contributes to a decline in physical and mental health and decreases academic success of nursing students (Karaca, Yildirim, Cangur, Acikgoz, & Akkus, 2019) . Conversely, maintaining mental health and wellness contributes to the ability of nursing students to feel, think, and act in ways that enable them to positively cope with the challenges they face (Government of Canada, 2015) .

"Higher education should be challenging, but not traumatic," (Goodard et al., 2021, p.1) and it is more important than ever to reflect on the presence or absence of trauma-informed educational approaches in respective curriculums. Similar to how nursing has developed traumainformed care approaches in a patient-centered care model, trauma-informed education should form the basis of a student-centered learning environment (Goodard et al., 2021) . Traumainformed educational approaches focus on the psychological safety of everyone in the learning environment and require educators to reflect on how they can avoid re-traumatizing or triggering students unnecessarily (Goodwin & Eales, 2020) .

When this study commenced in May 2020, there was an urgent need to collect data that could meaningfully assist nursing faculty and nursing programs in supporting students to prevent deterioration of their mental health during the onset of the COVID-19 pandemic. There was little literature about nursing students' experiences during a pandemic (Swift et al., 2020) , and existing literature mainly focused on a preparedness point of view or posed hypothetical questions related to potential pandemics (Goni-Fuste et al., 2021; Gu et al., 2019; Yonge et al., 2010) . Due to the scant accessible literature on nursing students and pandemic experiences, a need was identified to explore how nursing students' mental health was being impacted. Two years into this crisis, it has become clear that nursing education will be permanently changed by this global crisis, and the perspectives of students should be heard and considered when determining the way forward.

This study aimed to reveal the structure of the lived experiences of mental wellness of undergraduate licensed nursing students during the COVID-19 pandemic by asking the following question: What is the lived experience of nursing students' mental wellness during the COVID-19 pandemic? Along with preventing deterioration in the students' mental health, the aim of this research was also to understand the supports needed in the long term as the COVID-19 situation evolves, and to gain insight into the student perspective that can be shared with nursing education institutions as these institutions navigate through this unprecedented challenge.

To answer this question, a research team of three nursing faculty, and three nursing students was formed in the spring of 2020. This study was approved by the University of Regina Research Ethics Board (REB# 2020-103).

A descriptive phenomenological approach guided this study. Phenomenology is a diverse and complex philosophy that thematizes consciousness (Giorgi, Giorgi, & Morely, 2017) .

Consciousness is described as non-sensorial, and the means of how people become aware of all the material, physical, and biological phenomena that they encounter in everyday lived experiences (Giorgi, Giorgi, & Morely, 2017) . A descriptive phenomenological approach was selected as it is most appropriate when studying a phenomenon that is poorly conceptualized (Polit & Beck, 2017) . Giorgi (2009) presents a psychological approach to phenomenology and was selected due to the research purpose aimed at uncovering the essence of lived experiences of mental wellness of nursing students during COVID-19.

Although several studies have been done in the past year related to nursing students' mental health during the COVID-19 pandemic (Aslan & Pekince, 2021; Fitzgerald & Konrad, 2021; Gallego-Gomez et al., 2021; Kochuvilayil et al., 2021; Savitsky et al., 2021; Suliman et al., 2021; Sun et al., 2021) this study provides a unique perspective because of the methodology utilized. Descriptive phenomenology allowed the participants to focus on whatever mental wellness meant to them at that time without requiring them to talk only about their education.

Giorgi (2009) states that phenomenological research requires a minimum of three participants so that significant variations in the raw data will be captured. To facilitate variations in data, six participants were recruited. Participants were currently enrolled in a licensed undergraduate nursing program at Saskatchewan Polytechnic and the University of Regina, including students from the Saskatchewan Bachelor of Science in Nursing degree program, and students from the diploma and degree Registered Psychiatric Nursing (RPN) programs. To be eligible to participate, participants had to be 18 years of age or older, enrolled in any year in their respective program, and able to provide informed verbal consent. Purposive sampling efforts were made to recruit participants that spanned a wide range of programs with a wide representation of years in program, ages, genders, socioeconomic statuses, employment status, cultures, family/caregiver roles and physical location.

Recruitment took place through posters which were distributed electronically through student online portals. Potential participants then emailed a designated team member to be screened for eligibility which involved filling out a demographic form to ensure that diverse student populations were captured and to match participants with the most appropriate interviewer. Care was taken to match research assistants with participants that were not in their same program of study and to ensure that they did not know each other prior to the interview to further help protect participants' anonymity. Participants had time to review the consent form and ask questions prior to the interview.

Participants completed a single one-on-one interview which took place using online video conferencing in September and October of 2020. One broad open-ended question asking participants to "describe in as much detail as possible how COVID-19 has affected your experience as a nursing student" followed with prompting questions including "How has COVID-19 affected your mental health?" as needed to capture a thick and rich description of each participant's experience (Giorgi, 2009) . Interviews were approximately one hour in length.

All interviews were completed by the research assistants who were also nursing students to help participants feel safe and comfortable discussing their true experiences without fear of academic repercussions. Interviews were transcribed verbatim by the nursing student researchers and transcriptions were checked for accuracy by another team member.

The interviewers kept field notes of their observations immediately following each interview and discussed each interview and their perceptions with the nursing faculty involved in the project. Mentorship and support were present through the entire process.

The scientific rigor of the findings was maintained through concurrent recruitment of participants and data analysis until no new information immerged and consensus was reached within the research team that the criteria of data saturation had been met. Furthermore, Giorgi (2009) ascertains the number of participants is not a key focus but rather the richness of the description of each participant's account of their experience.

Contact with participants, and research team meetings were completely virtual to abide by local public health orders that limited private and public gatherings to less than 8 people and required social distancing as well as masking in all public spaces. Virtual interactions protected the health and safety of all participants. At the time, all local nursing programs were occurring completely online apart from face-to-face clinical practice.

The descriptive phenomenological psychological method, as described by Giorgi (2009) was used for data analysis. Prior to data analysis members of the research team utilized bracketing in which the researchers' past experiences and knowledge is written out and reflected on, so that it does not interfere with the present analysis of the phenomenon as experienced by another (Giorgi, 2009) . Each transcript was read line by line to separate the text into meaning units. The meaning units are single ideas within a larger body of text and are noted by marking the data each time there is a shift in the meaning (Giorgi et al. 2017 ). This was completed without the utilization of any research software. Data analysis after the initial meaning units involved further describing these meaning units in terms of their implications. It is important to note that by following this methodology closely, this step does not involve any interpretation. As shown in Table 1 , it is only varying the description to reveal the true essence of each statement.

The research assistants completed this step of analysis and then the entire research team met to validate the meaning units. Giorgi notes that different people conducting the method on the same data may denote slightly different meaning units, and this is okay. The meaning units have a practical use to break the data into more manageable sections. It is most important that when they are reintegrated into the overall structure of the phenomenon that they maintain their initial integrity from the raw data (Giorgi, 2009 and as well as with P1's other friends, they can sympathize, but it feels like P1 and their friends don't have as much support from the teachers as they would in person, which is another big factor. P1 feels like they are kind of stumbling through courses by themself.

Friends understand, but teachers are not as supportive as they are in person. The participant feels alone in their coursework.

So it's just been very stressful and that stress has been taking a toll on P1's grades and just their mental health, as well as anxiety too.

Stress has caused a negative impact on grades, and mental health. The participant has experienced stress and anxiety. With faculty it's like it's new for them even which P1 understands... it's hard for everyone.

The participant understands that the pandemic has also been hard for faculty. This led to the next step in analysis which was to look for ways that the essences were described by all participants. This was done by making a constituents table. As constituents were identified from the essences they were listed in a table with supporting statements from each transcript, as depicted in Table 2 . Constituents that were not supported by each description were eliminated as they were deemed non-essential to the structure of the phenomenon (Giorgi, 2009 ).

The entire research team met to discuss the constituents table and validate the key makeup of the essence of the described phenomenon. (Insert Table 2 Here)

Five of the participants identified as female, and one as male. One participant was a student in the baccalaureate psychiatric nursing program year 1, and the other participants belonged to the baccalaureate nursing program in years 1, 2 and 4. Two participants identified as White, while the remaining participants were of diverse cultural and ethnic backgrounds including Black, Métis, Chinese and Filipino. They ranged in age from 19-36 with a mean age of 23. Year 4 21 (-0.37)

Key elements of the lived experience of mental wellness during the pandemic included shifting support systems, disconnection, continual adaptation, worry, sense of missing out, and environmental stress. Change and adaptations required in all areas of students' lives: academic, personal, and social/societal. None of the descriptions were completely negative or positive, and at times, even parts of the description that were initially experienced as negative to the student, such as the stress of switching to online learning, later became a more positive element in their experience. It is evident in responses that participants experienced multiple losses during the initial stages of the pandemic which in many cases resulted in distress and upheaval of their current way of living. There was also the experience of living in fear of potential loss, a type of anticipatory grieving, where students were constantly aware that things might get worse and that others were in worse situations.

Participants described support of family, friends, nursing student colleagues and faculty.

P4: "I am lucky that I got support from my family, from my school, from my university…They want you to be successful." P1: "I was able to spend more time with my parents than I normally would. We had opportunity to talk to them more, bond with them."

However, this support was not always constant, due to the changing public health restrictions, the challenge of interacting over technology and the inability to interact as often or in ways that they would prefer with those that they are close to.

P3: "I find a big part of nursing is kind of like that social and peer support …so now with everything online and over zoom, is just definitely not the same"

All participants described the pandemic as causing some sense of disconnection that affected their mental wellness. Some disconnection was directly related to physical isolation required at different times, but also was expressed in terms of not knowing their peers as well because they are not able to be physically together, and also in terms of a loss of community.

Even the physical barrier of masks caused one participant to express they felt a disconnection from others.

P2 "It is hard to form that relationship with someone when sixty percent of your face is covered."

P6: "So I don't even know most of my class. I know 8 people. Sometimes when people are presenting, someone will pop up on the zoom screen and it's like, I've never seen you before."

Change and adaptation was the only constant and was described as having both negative and positive effects on the students' mental wellness.

P2: "Everything was just totally thrown into this big loop…..Monday…everything was normal and then Tuesday, you have to show your student ID to get let into a hospital because they aren't allowing visitors anymore."

P2: "It's learning to adapt to something you don't want to adapt to. I don't really want to learn how to live in a world where we can't see family because of a virus."

Students reported that the nursing programs made several changes that they appreciated, such as changing course offerings to be more accommodating and modifying course content to an online format. As well, they acknowledged great efforts were made to help students continue their studies and finish their courses and programs on schedule. The quick change to online learning required participants to adapt their study habits and develop discipline to stay motivated.

P3: "the program did do as good as they could have done in the circumstances, but I feel like everyone was just kind of unprepared for a pandemic and what went down."

All participants described that the pandemic has increased their levels of worry and anxiety. As with all elements of the descriptions of their experiences, even worry was not stagnant. This worry was at times overwhelming and all-consuming yet at other times shifted to manageable and was perceived as temporary. Participants worried about the impacts on their learning, their ability to graduate on time, and their finances.

P1: "I was anxious about how maybe I would have to do an extra year of schooling, and I really don't want to do that.

Additionally, they worried about the potential of spreading the COVID-19 virus to patients, friends, and family, seemingly more than they worried about the potential of themselves becoming sick.

P6: "the possibility of getting anyone sick, especially an immunocompromised person; It was scary."

The sudden changes to their nursing education caused participants to wonder about what a typical education would have been like. They expressed feelings of loss related to how they felt their nursing education was going to be versus how it was happening in reality. They knew they

were not able to have the full experience of hands-on learning that normally occurs, such as time to practice hands on skills with instructors on campus, or even the choice of certain clinical settings that interested them.

P5: "I feel like I'm not getting the full nursing student experience. I miss having labs, because those are all online now. I feel like I'm really missing out on that experience and getting the chance to practice."

Special events and academic milestones such as pinning ceremonies and graduations were shifted to a virtual format and social events for students were cancelled. Cumulative losses and the sense of missing out contributed to a decline in mental wellness.

P1:"I kind of feel like a part of the degree was kind of stolen from me right?"

The participants' mental wellness was greatly impacted by what was going on around them in the nursing faculty, their workplaces, and communities.

P2: "The world's in a bad place, so that impacts mental health too… well I'm not looking out my window and seeing kids playing around in their parking lot anymore"

They were sensitive to the reactions of others that they observed, one participant noting that everyone seemed to be tired, another noting that instructors are more frustrated and on-edge.

P4: "(I) don't want to bother people because you're seeing people are maybe very, very tired or something. So, you don't ask questions, you don't chat with people during the breaks."

One participant discussed how negative news was overwhelming and another described how witnessing panic and anxiety in others was contagious at times. P1: "Everyone was reacting like; you know they were panicking and seeing them panic kind of made me feel panicky. That type of behavior kind of spreads onto everyone else, and it's hard to kind of stay calm right?"

The elements described above constitute the essential structure of the students' mental wellness. Understanding the relationship of the constituents to each other and looking at the whole structure, the experience is also described as a traumatic event. Giorgi explains that one reason this methodology works to build knowledge is that the descriptions always "reveal more than what the describer is aware of" (2009, p. 181) . The research team agrees with Giorgi's statement, because the participants descriptions clearly reflect an experience of a traumatic event even though none of the participants explicitly used that language to explain how they were feeling.

When encouraged to expand on whatever was important to them, by using phenomenological interviewing techniques, nursing students described their experiences in the COVID-19 pandemic in a holistic way, reflecting the way mental health and wellness permeates all aspects of our lives. Several common themes were identified across the descriptions and the overarching experience revealed itself as trauma.

Understanding that nursing students in this study describe experiencing a traumatic event makes it clear that the mental health of nursing students needs to be a priority for educators.

Firstly, educators need to acknowledge that students are experiencing on-going trauma related to the COVID-19 pandemic (Goddard et al., 2021; Zhai & Du, 2020) . This trauma puts nursing students at risk for other mental health issues such as depression and post-traumatic stress disorder and compassion fatigue as well as negatively impacting the student's ability to learn (Goodard et al., 2021) . Trauma-informed education should not be confused as a recommendation to make nursing education easier for students, but instead as embracing trauma-informed principles, such as safety, choice, collaboration, and trust to create a supportive and nurturing environment where students can be successful in their learning and experience personal growth (Goodard et al., 2021; Goodwin & Eales, 2020) . Nursing faculty can be leaders in this new reality of post-secondary education going forward and several strategies to engage in traumainformed educational approaches are described below.

Although uncomfortable, the trauma experienced during the pandemic can serve to build resilience in individuals (Mueller, 2021; Zhai & Du, 2020) . Increased resilience contributes to future nurses' ability to positively adapt to challenges in stressful environments while avoiding burnout (Henshall et al., 2020; Mueller, 2021; Walsh et al., 2020) . Participant responses reflect these opportunities for growth when indicating adaptation to the continual changes brought on by the pandemic required them to build new skills. It is important to note students will often require guidance to work through these challenges that lead to the building of resilience. Potential strategies to promote the development of resilience in nursing education could include validating students' experiences, acknowledgement of stressors, modelling coping strategies such as positive self-talk (Mueller, 2021) incorporating exercise or mindfulness in their lesson plans (Walsh et al, 2020) , encouraging engagement in reflective practice to note areas of growth (Holdsworth, 2017; Walsh et al., 2020) , developing relationships to foster safe learning spaces (Holdsworth, 2017; Walsh et al., 2020) and/or encouraging students to consult professional counselling services whenever concerns arise.

It was not surprising that nursing students described increased levels of stress and anxiety since the beginning of the COVID-19 pandemic. This finding is similar across other studies (Aslan & Pekince, 2020; Fitzgerald & Konrad, 2021; Kochuvilayil et al., 2021; Savitsky et al., 2020) . However, the participants were also greatly affected by their perceptions of the stress of those around them including nursing faculty and other nursing professionals they observed in clinical situations. In the initial stages of the pandemic, as society faced major upheaval and there was so much unknown, the students described looking to faculty for stability, information and compassion but did not always receive what they needed which negatively impacted their mental wellness. This finding aligns with additional studies (Fitzgerald & Konrad, 2021; Savitsky et al., 2020) which also identified that students were relying on faculty for stable and structured learning environments with flexibility and understanding provided when needed.

Additionally, participants described disconnection from those around them as affecting their mental wellness. Faculty should provide nursing students with support systems to prevent on-going or worsening isolation and disconnection (Aslan & Pekince, 2020; Fitzgerald & Konrad, 2021; Shaw, 2020) . This could involve assisting students to connect with each other and form their own support networks or could be assisting students to access more formal support systems such as counselling. Students are usually quite able to form their own support groups among their peers, but in a completely online environment, this was difficult for students to do on their own. Faculty could help by incorporating more creative ice-breaker activities in their online courses and encouraging students to reach out to each other. It is important to note that some mental health support services were closed or scaled-back early in the pandemic without acceptable alternatives being made available to people in need (Mueller, 2021) . As participants in this study pointed out, it is unacceptable and harmful to provide empty promises of support or refer students to services that are no longer available or are otherwise in-accessible to them.

Although inexperienced, the inclusion of nursing students on the research team greatly enhanced the research process and was a benefit to the participants and the faculty involved. The collaboration between nursing students and faculty throughout the entire research process ensured that the true nursing student perspective was indeed heard and the students on the team provided invaluable context about how best to approach students with this topic. Using descriptive phenomenology provided for rich and detailed accounts of the experiences of the participants, but also required a smaller sample size and therefore it was impossible to sample from all possible variations of nursing students. Effort was made to sample a diverse population;

however, no claim can be made that the data represents the diversity of the student body.

The COVID-19 pandemic has had a profound impact on the mental wellness of nursing students. Students describe mental wellness as impacting their lives in three domains: their personal relationships, their academic studies, and their social environment (society and community). They described shifting support systems, disconnection, continually adapting, worry, sense of missing out, and environmental stress as essential elements of their current experience. This description can be compared to the experience of an on-going traumatic event and should inform nursing education in the months and years to come as we reimagine the future of nursing. A trauma-informed learning environment, where nursing students feel safe to express their stresses, are able to observe and practice positive coping mechanisms, and are assisted to form meaningful support systems can be incorporated into nursing education practice today. 

Nursing students' views on the COVID-19 pandemic and their perceived stress levels

Decreasing stress and supporting emotional well-being among senior nursing students: A pilot test of an evidencebased intervention

Lifestyles, Depression, Anxiety, and Stress as Risk Factors in Nursing Apprentices: A Logistic Regression Analysis of 1193 Students in Lima

Stress in nursing students: study on sociodemographic and academic vulnerabilities

Transition in learning during Covid-19: Student nurse anxiety, stress, and resource support

The Covid-19 pandemic and its impact on homebound nursing students

The descriptive phenomenological method in psychology: A modified Husserlian approach

Trauma informed education in nursing: A call for action. Nursing Education Today

Trauma informed pedagogy: Rethinking the use of graduated instructional prompts in inclusive physical education

Experiences and needs of nursing students during pandemic outbreaks: A systematic overview of the literature

About mental health

Factors influencing disaster-incident related impacts on Korean nursing students

Nursing resilience interventions: A way forward in challenging healthcare territories

… Not drowning, waving. Resilience and university: a student perspective

Relationship between mental health of nursing students and coping, self-esteem and social support

Covid-19: Knowledge, anxiety, academic concerns and preventative behaviours among Australian and Indian undergraduate nursing students: A cross-sectional study

Development and testing of the university student resilience scale

When a clinical crisis strikes: Lessons learned from the reflective writing of nursing students

Nursing research: Generating and assessing evidence for nursing practice

Resilience in Nursing Education: An Integrative Review

Anxiety and coping strategies among nursing students during the COVID-19 pandemic

Hopelessness, helplessness and resilience: the importance of safeguarding our trainees' mental wellbeing during the COVID-19 pandemic

Experiences of nursing students under the unprecedented abrupt online learning format forced by the national curfew due to COVID-19: A qualitative research study

Disease prevention knowledge, anxiety, and professional identity during COVID-19 pandemic in nursing students in Zhengzhou China

Covid-19 and student nurses: A view from England

Learning and teaching approaches promoting resilience in student nurses: An integrated review of the literature

Willingness of university nursing students to volunteer during a pandemic

Loss and grief amidst COVID-19: a path to adaptation and resilience

The research team would like to acknowledge the nursing students that participated in this study and thank them for sharing their experiences.

The authors have no competing interests to disclose.