key: cord-0764108-fu7eoz9b
authors: Vázquez‐Calatayud, Mónica; Rumeu‐Casares, Carmen; Olano‐Lizarraga, Maddi; Regaira Martínez, Elena
title: Nursing students' experience of providing frontline COVID‐19 support: A qualitative study
date: 2021-11-22
journal: Nurs Health Sci
DOI: 10.1111/nhs.12902
sha: 3ce4d6a168cd5fed0965bb5b4a366a837a468511
doc_id: 764108
cord_uid: fu7eoz9b

Understanding the unique experience of nursing students providing frontline support in COVID‐19 hospital wards is crucial for the design of strategies to improve crisis management and mitigate future pandemic outbreaks. Limited research concerning this phenomenon has been published. This qualitative study aimed to understand the experience of providing support from COVID‐19 frontline nursing students' perspective. Online interviews were conducted with nine nursing students from April to May 2020; interview data were analyzed by content analysis using Burnard's method. Six main categories emerged from the data analysis: “experiencing a rapid transition from student to professional,” “fear and uncertainty of the unknown,” “resilience throughout the crisis,” “sense of belonging to a team,” “shared responsibility,” and “importance of the profession.” Based on these findings, multicomponent strategies that function in parallel with practical contexts should be developed to enable students to diligently adapt their abilities to their new role and cope with health crises.

Globally, pandemics constitute one of the main threats to the security and survival of humanity (Malik et al., 2020) . On March 11, 2020, the World Health Organization (WHO) declared COVID-19 a pandemic. This situation has led to a major public health crisis due to the lack of capacity, resources, and direction of health systems (The Lancet, 2020).

To face this crisis, in Spain and other European countries, such as the United Kingdom or Israel, final-year undergraduate nursing students have been required to provide frontline care (Health Education England, 2020; Ministry of Health, Government of Israel, 2020; Ministry of Health, Government of Spain, 2020). This measure, although exceptional and voluntary, had already been successfully implemented more than a decade prior in Canada in the face of the influenza pandemic (Rosychuk et al., 2008) .

Throughout the curricular practices of the degree, nursing students are prepared to transition adequately from the role of student to that of a professional, as they begin to assume responsibilities in clinical practice and to develop critical thinking skills in problem solving (Admi et al., 2018; Sharif & Masoumi, 2005) . These practices, however, generate stress for these students, due partly to their inexperience and lack of uncertainty about the practice context, patient complexity, and a fear of making mistakes (Ab Latif & Mat Nor, 2019; Moridi et al., 2014; Pulido-Martos et al., 2012) . Nursing students' stress levels are accentuated by the emotional challenges they experience associated with the suffering of patients and their families, the proximity to death, and the difficulty of interpersonal relationships in the work environment (Ranse et al., 2018) . Moreover, during the COVID-19 pandemic, high levels of stress and anxiety related to uncertainty (De Gagne et al., 2021) associated with fear of infection have been reported (Huang et al., 2020; Savitsky et al., 2020) , especially among those on the front lines (Huang et al., 2020) .

The literature published in recent months reflects a growing interest in exploring the perspective of final-year nursing students in this context.

A series of studies have examined the impact of the pandemic on this population's mental health (Gallego-G omez et al., 2020; Huang et al., 2020; Rosenthal et al., 2021; Savitsky et al., 2020) and attitude toward the change to an online learning modality (Ramos-Morcillo et al., 2020; Thapa et al., 2021) , as well as their contributions to social media (De Gagne et al., 2021) . In addition, several studies and editorials investigating the experiences of nursing students who cared for patients with COVID-19 on the front lines have been published in scientific journals (Cervera-Gasch et al., 2020; Hernández-Martínez et al., 2021; Leigh et al., 2020; Lowes, 2020; Swift et al., 2020) . However, thus far, few published research studies have explored this experience of providing care (Casafont et al., 2021; Collado-Boira et al., 2020; Velarde-García et al., 2021) . A qualitative approach to understanding individual frontline experiences of final-year nursing students is crucial to support the design of educational and management strategies to improve the management of the current pandemic and future similar outbreaks (Rosenthal et al., 2021) . Thus, this study aimed to understand nursing students' experience of providing frontline COVID-19 support.

A qualitative descriptive study following the approach described by Sandelowski (2010) was conducted in several COVID-19 hospital wards on two campuses located in Pamplona and Madrid of the University of Navarra Clinic (Spain), a third-level medium-sized university hospital providing services to the Government of Navarra during the State of Alarm. A qualitative descriptive approach was implemented to allow for a closer analysis of the data, words, and events described.

This approach is ideal for obtaining knowledge regarding and identifying the lived experience of final-year nursing students providing frontline care during the pandemic.

The sample consisted of nine fourth-year students of the Nursing Degree at the University of Navarra whose clinical practices had been interrupted and who had been hired as "nursing support health aides," a form of support personnel who always provide care under the supervision of a health professional. The participants completed all theoretical subjects and 65 ECTS (European Credit Transfer and Accumulation System); part of their final module of practical clinical training (20 ECTS), which covered training activities such as clinical cases and simulations, and their graduation were delayed due to the pandemic.

To access the sample, the Nursing Professional Development Area at the University of Navarra Clinic contacted the Study Coordinator of the Faculty of Nursing at the University of Navarra. Of the 46 candidates, 20 fourth-year nursing students were recruited to support the University of Navarra Clinic from March 31 to April 8, 2020, and 13 nursing students were recruited to provide support in Madrid from March 3 to May 11, 2020. The students who transferred to the University of Navarra Clinic on the Madrid campus were given accommodations in several hotels provided to the Community of Madrid to host health professionals. The researcher who conducted the interviews contacted, through the coordinator, those students who had been hired and who showed interest in participating in the study. The same person sent an email to those who provided their contact details and wanted to participate. After obtaining students' permission, the researcher explained the project and made interview appointments.

Purposive sampling was applied to ensure that the participants provided key information about the phenomenon explored. In addition, the snowball technique was used by asking participants to invite other classmates to participate in the study. Students who had provided support in a COVID-19 ward at one of the two centers, during any shift (morning, afternoon, or night), and who had agreed to volunteer to participate in the study were included.

Semi-structured interviews were conducted virtually with each student by one member of the research team between April and May 2020. The interviews were recorded and transcribed verbatim, and lasted between 30 and 60 min. The thematic guide used was developed based on a review of the literature on other pandemics (Table 1 ). In addition, field notes were taken on aspects that could complement the data obtained through the interview and to collect participants' sociodemographic data to help better understand and contextualize each interviewee (Table 2) . Students were recruited until sufficient experiential material was available for in-depth descriptions and the new data collected were found to be redundant, thereby ensuring data saturation (Procter & Allan, 2012) .

The thematic content analysis of the data used the method proposed by Burnard (1996) . This analysis consists of repeatedly listening to the participants and reading the transcripts to understand the meaning of participants' expressions and descriptions of their experience during the pandemic. This process was carried out by the first and last authors first independently and then jointly. Codes or labels capturing the statements, words, descriptions, and concepts expressed by the participants were generated. Then, these codes were grouped and regrouped into general themes (i.e., thematic categorization). Finally, the distinctive characteristics of each theme were identified and described to identify constructs until the final themes integrating all informants' perspectives were formed (see Table 3 ). These final phases of the analytic process were discussed and agreed upon by the entire research team. NVivo VS 20 software was used to organize the qualitative data.

To ensure study quality, the criteria described by Lincoln and Guba (2000) for credibility, consistency, transferability, and confirmability were used ( 

If I ever got down, I have to move on, especially for the patients; they need me. (NS6) Being able to discuss it with your colleagues … it helped me a lot to cope with the situation. (NS5) Being able to work in a good work environment has helped me a lot to cope better. (NS8) 4. Sense of belonging to a team As the days went by … you felt like one of the team. (NS5) In these situations it is essential to be part of a team and to be all coordinated. (NS5)

Although I was there to help … in that sense it was a shared responsibility. (NS2) I felt that, although I had responsibility for what happened, that responsibility was shared. (NS5) 6. Importance of the profession I realized the power of our profession. (NS5) Living such an extreme situation has meant an important change in the profession (NS6) V AZQUEZ-CALATAYUD ET AL.

Qualitative Research (COREQ) checklist was used for the reporting (Tong et al., 2007) . Likewise, throughout the process, the researchers considered their own reflexivity, being aware and reflexively self- 

The study participants received verbal and written information regarding their voluntary participation, data confidentiality, and anonymity, and the use of their data for scientific purposes. Participants gave signed consent before the interview. The research was approved by the Research Ethics Committee of the University of Navarra (code 2020.155) and by the University of Navarra Clinic's management team, and was performed in accordance with the criteria of the Declaration of Helsinki (World Medical Association, 2013).

The sample consisted of people aged 20-22, 89% of whom were female (n = 8). Six key categories emerged from interview analysis:

(i) experiencing a rapid transition from student to professional; (ii) fear and uncertainty of the unknown; (iii) resilience throughout the crisis;

(iv) sense of belonging to a team; (v) shared responsibility; and (vi) importance of the profession. The quotation data are codified with labels consisting of the letters NS plus the number assigned to the interviewed nursing student.

This theme refers to the lived experience of participants transitioning from student to professional and from the academic setting to the clinical environment. This transition was characterized by its suddenness, prompted by the pandemic, and insufficient time to assimilate or prepare for the change. This short period involved an adaptation process that, based on participants' reports, comprised five phases:

(i) perceived fear of moving away from usual sources of support (family, friends, and university); (ii) loss of reference points (teachers);

(iii) frustration and helplessness at not knowing how to help and feeling "in the way" or "a burden"; (iv) adaptation to a new situation as a professional; and (v) a feeling of satisfaction and personal and professional growth. In this last phase, participants came to feel that they were useful and had learned both self-awareness and useful strategies for working within a team and with patients, thereby feeling capable of transitioning from student to professional. 

Resilience during the crisis consisted of the students' ability to overcome the adverse situation posed by the pandemic and emerge stronger. All participants showed two characteristics enabling their resilience: a sense of responsibility and persistence. The sense of responsibility was motivated by the patients' situation, which made participants aware of their role, the need to do their best, and the potential positive impact of their actions. Persistence meant they were able to keep going, despite the difficulties, as reflected in the fol- The students also discussed the barriers and facilitators to overcoming this situation and emerging stronger. Among the main barriers were the lack of time to "be" with the patient and the chaos of the crisis, which made coping with the situation difficult. The lack of time to be with the patient included the lack of time both to stay in the room and to engage in conversation and active listening. The chaos of the crisis was generated by the disorganization of services in terms of material resources and the distribution of patients. 

Another theme participants repeatedly expressed was the feeling of belonging to a team. The students noted that it was key to identify with the other team members to share experiences and emotions and the common goal of providing the best patient care to perform their work better.

As the days went by … you felt like one of the team, and I was very grateful for that because it is important to be comfortable in your work environment in these situations to be able to work better … that they would trust you is something to be grateful for because we had no experience and they treated us like a team member.… In these situations, it is essential to be part of a team and to be all coordinated so everything goes well and the patient is well cared for. (NS5)

Most students indicated having shared responsibility with more experienced nursing staff. This co-responsibility occurred both in contexts where the patient was critical, requiring someone to supervise their care at all times, and in the ward, where the condition of a patient could rapidly deteriorate, and participants had to assume responsibility with another colleague for assessment and early detection. 

This study generated knowledge regarding the experience of nursing students providing frontline support in COVID-19 hospital wards.

Data analysis revealed this experience as one involving rapid transition from student to professional, fear and uncertainty in the face of the unknown, resilience throughout the crisis, the sense of belonging to a team, shared responsibility, and the importance of the profession.

The findings of this research have contributed to clarifying the process of transition from student to professional in an exceptional situation, such as a pandemic. This process is characterized by the rapid sequence of five phases: (i) perceived fear of moving away from usual sources of support; (ii) loss of reference points; (iii) frustration and helplessness at not knowing how to help and feelings of being "in the way" or "a burden"; (iv) adaptation to the new situation as a professional; and (v) a feeling of satisfaction and personal and professional growth. The duality of feelings identified throughout this process is consistent with previous studies describing the transition from student to professional as an experience of ups and downs, characterized by feelings of both frustration and satisfaction (Kaihlanen, 2020; Kaihlanen et al., 2018) . Moreover, the findings regarding the sequence of the phases partially coincide with the assumptions defended by Schoessler's theory of transition stages (Kaihlanen et al., 2018) . This theory postulates that the transition from student to nursing professional occurs in three main stages:

(i) approaching the transition; (ii) evaluating the situation to cope with it;

and (iii) completing the transition, which resembles the process identified in this study. The first three phases identified herein would be grouped into the first stage of the process defined in Schoessler's theory (Schoessler & Waldo, 2006) , with the second and third stages corresponding to the last two phases. In contrast to this theory, we found the transition from one phase to another, as driven by the pandemic, to be rapid.

In the last two described phases of the transition process, students' ability to overcome the adverse situation of the pandemic and emerge stronger is also evident. This resilience derived from two student attributes: a sense of responsibility for the patient and persistence. In light of these findings and based on suggestions by several theorists that resilience in the context of COVID-19 can be learned (Shaw, 2020; Taylor et al., 2020) , it is suggested to teach both competencies to prepare students for future pandemics, for example, through narratives, simulation, or role modeling (Taylor et al., 2020) . In the same way, based on this research, it is recommended to incorporate effective coping strategies, such as with sharing lived experiences with other students, for example, or with the death of patients or their mourning.

The findings of this study, in addition to having interesting implications for the academic context, provide key evidence for practice.

The results reveal that a positive organizational climate, characterized by open communication, collaborative work, and an empathetic attitude toward students, supports students' resilience by helping them feel more confident, trusted, and part of a team. These results are consistent, in part, with those obtained in a similar study conducted in Spain and published recently, in which students were highly accepted by care teams during the pandemic (Casafont et al., 2021) . This positive reception of students by care teams can be attributed to the context because emergencies encourage professionals to assume other types of interprofessional collaboration dynamics that differ from the daily dynamics (Reeves et al., 2010) .

Another significant finding, which has also been reported in other studies (Collado-Boira et al., 2020; Huang et al., 2020) , was fear and uncertainty in the face of the unknown, motivated by participants' insecurity regarding their ability to cope with the situation, both personally and professionally, partly because of the interruption of their final-year practical training. In this study, this insecurity was overcome after becoming familiar with the environment and the situation during the last two phases of the transition process. Unlike other studies (Collado-Boira et al., 2020; Huang et al., 2020; Savitsky et al., 2020) , in this study, students explicitly stated that the fear of being infected was one of the aspects that concerned them the least. This fact may be due to the sociodemographic characteristics of the sample, which could influence this perception, as well as organizational factors, because, as the participants point out, these were organizations that had a COVID-19 control committee that reviewed the pandemic containment measures weekly, updated the procedures according to the evolution of the pandemic, and communicated such changes to all professionals. In addition, they had material resources, received training for the proper application of protocols, and were monitored by unit supervisors.

Finally, of particular importance is the positive impact, through providing frontline support in COVID-19 hospital wards for the nursing students in this study, of strengthening the value of nursing professionals and their recognition and visibility. This finding, which is partially consistent with previous studies (Huang et al., 2020; Leigh et al., 2020; Lowes, 2020) , may be associated with the support students felt at all times through sharing the responsibility of care, their experiences among peers, and common goals with the entire team to provide the best patient care.

This study has important implications for nursing education. In particular, it has shown the potential benefits for future graduates if, during their undergraduate education, they are given guidance on the stages and experiences they will experience in their transition to becoming professionals. In this regard, for instance, they could be trained in coping strategies to become more resilient and better respond to a crisis or future health disasters. Furthermore, in relation to nursing management, this study has highlighted the need for organizations and unit managers to encourage teams to work collaboratively and to promote open communication and a positive working environment. Such environments will help both students and new employees feel more welcome and supported by the staff.

As a limitation, this qualitative research collected the experiences of final-

year nursing students in two specific health care contexts. Therefore, the findings are relevant to the contexts in which the study took place and to the perceptions of a limited number of participants. However, the findings of this study are not intended to be generalized but rather to provide indepth knowledge about the reality perceived by the students included in the study. Therefore, it would be advisable to develop similar research in other contexts to improve the understanding of the phenomenon.

This study has provided evidence on the experiences of nursing students during the COVID-19 pandemic. This knowledge, which is crucial for the design of educational and management strategies to improve the management of the COVID-19 crisis and similar future pandemic outbreaks, needs to be further deepened by conducting new qualitative studies in other contexts. Preliminarily, we propose the development of multicomponent strategies dealing with both the contexts of practice and students' abilities to adapt diligently to their new role and cope with health crises.

We wish to express our gratitude to the nursing student participants who made this study possible.

V AZQUEZ-CALATAYUD ET AL.

Stressors and coping strategies during clinical practice among diploma nursing students

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Teaching the analysis of textual data: An experiential approach

Experiences of nursing students as healthcare aid during the COVID-19 pandemic in Spain: A phemonenological research study

COVID-19: Are Spanish medicine and nursing students prepared?

The COVID-19 outbreak"-An empirical phenomenological study on perceptions and psychosocial considerations surrounding the immediate incorporation of final-year Spanish nursing and medical students into the health system

COVID-19: Protecting health-care workers

A qualitative analysis of nursing students' tweets during the COVID-19 pandemic

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From a nursing student to a registered nurse

Facilitating the transition from a nursing student to a Registered Nurse in the final clinical practicum: A scoping literature review

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Paradigmatic controversies, contradictions, and emerging confluences

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Order SND/232/2020, of March 15, adopting measures in terms of human resources and means for managing the health crisis situation caused by COVID-19

Clinical training stress-inducing factors from the students' viewpoint: A questionnaire-based study

Sampling

Sources of stress in nursing students: A systematic review of quantitative studies

Experiences of nursing students during the abrupt change from face-to-face to e-learning education during the first month of confinement due to COVID-19 in Spain

Third-year nursing students' lived experience of caring for the dying: A hermeneutic phenomenological approach

Interprofessional teamwork for health and social care

A survey of mental health in graduate nursing students during the COVID-19 pandemic

Willingness to volunteer during an influenza pandemic: Perspectives from students and staff at a large Canadian university. Influenza and Other Respiratory Viruses

What's in a name? Qualitative description revisited

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

The first 18 months in practice: A developmental transition model for the newly graduated nurse

A qualitative study of nursing student experiences of clinical practice

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

COVID-19 and student nurses: A view from England

Teaching empathy and resilience to undergraduate nursing students: A call to action in the context of Covid-19

Nursing students' attitude on the practice of e-learning: A cross-sectional survey amid COVID-19 in Nepal

Consolidated criteria for reporting qualitative research (COREQ): A 32-item checklist for interviews and focus groups

The challenges of "learning on the go": A qualitative study of final-year Spanish nursing students incorporated to work during the first Covid-19 pandemic. Nurse Education Today, 103, 104942. World Economic Forum

Nursing students' experience of providing frontline COVID-19 support: A qualitative study

The data presented in this manuscript are original and are not under consideration elsewhere. In the present work, we do not have any conflicts of financial interest. 

The data that support the findings of this study are available from the corresponding author upon reasonable request.